1. Title: The Science of Safety
Armstrong Institute for Patient Safety and Quality
Presented by: David A. Thompson, DNSc, MS, RN
Title: Associate Professor

2. Learning Objectives
To recognize that every system is designed to achieve the results it gets
To identify the basic principles of safe design that apply to both technical and team work
To discuss how teams make wise decisions

4. RAND Study Confirms Continued Quality Gap
Condition
% of Recommended Care Received
Low back pain
68.5
Coronary artery disease
68.0
Hypertension
64.7
Depression
57.7
Orthopedic conditions
57.2
Colorectal cancer
53.9
Asthma
53.5
Benign prostatic hyperplasia
53.0
Hyperlipidemia
48.6
Diabetes mellitus
45.4
Headaches
45.2
Urinary tract infection
40.7
Hip fracture
22.8
Alcohol dependence
10.5
1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.

5. The Problem is Large In U.S. Healthcare system
7% of patients suffer a medication error 2
On average, every patient admitted to an ICU suffers an adverse event 3,4
44, ,000 people die in hospitals each year as the result of medical errors 5
Nearly 100,000 deaths from HAIs 6
Estimated 30,000 to 62,000 deaths from CLABSIs 7
Cost of HAIs is $28-33 billion 7
8 countries report similar findings to the U.S.
2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995
3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.
5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.
6. Klevens M, Edwards J, Richards C, et al., PHR, 2007
7. Ending Health Care-Associated Infections, AHRQ, 2009.

6. How Can These Errors Happen?
People are fallible
Medicine is still treated as an art, not science
Need to view the delivery of healthcare as a science
Need systems that catch mistakes before they reach the patient

7. Understanding the Science of Safety

8. 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 decisions when there is diverse and independent input
Caregivers are not to blame

9. System Failure Leading to This Error
Communication between
resident and nurse
Inadequate training
and supervision
Catheter pulled with
Patient sitting
Patient suffers
Lack of protocol
For catheter removal
Venous air embolism
8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.
9. Reason J, Hobbs A., 2000.

11. System Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
10. Adapted from Vincent C, Taylor-
Adams S, Stanhope N., BMJ, 1998.

12. Evidence Regarding the Impact of ICU Organization on Performance
Physicians11
Nurses12
Pharmacists13
11. Pronovost P, Angus D, Dorman T, et al., JAMA, 2002.
12. Pronovost P, Dang D, Dorman T, et al., ECP, 2001.
13. Pronovost P, Jenckes M, Dorman T, et al., JAMA, 1999.

13. Fatal Aviation Accidents per Million Departures
14. Statistical Summary of Commercial Jet
Airplane Accidents, Aviation Safety
Boeing Commercial Airplanes, July 2009.

14. 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. Standardize

16. Line Cart Contents – 4 Drawers

17. Eliminate Steps

18. Create Independent Checks

19. Principles of Safe Design Apply to Technical and Team Work

20. ICU Physicians and ICU RN Collaboration
% of respondents reporting above adequate teamwork
17. ICUSRS Data from Needham D, Thompson D,
Holzmueller C, et al., Crit Care Med, 2004.

21. Train & Coach Adaptive Team Behaviors
Leadership
Delegation
Resource management
Modeling good teamwork skills
Communication
Closed-loop communication
Using clear, structured communication
Mutual Support
Task assistance
Conflict resolution
Feedback
Situation Monitoring
Shared mental models
Cross-monitoring
TeamSTEPPS® Competency Framework
Teamstepps.ahrq.gov

22. Team Training: Does it work?
Team training is a strategy for systematically improving teamwork competencies: the knowledge, skill, and attitudes (KSAs) underlying effective teamwork.
Team training significantly improves team1:
Cognition (ρ = .42)
Shared mental models
Behavioral process (ρ = .44)
Communication, coordination, collaboration
Affect (ρ = .35)
Mutual trust, collective efficacy
Performance outcomes (ρ = .37)
Task outcomes, satisfaction, viability
1Salas et al., 2008

23. But, Does it Work in Healthcare?
Learner reactions are positive 1,2
Learning occurs 1,2
Behavior change in transfer environment occurs.1,2
Improved efficiency in clinical processes3-6
Improved clinical outcomes7,8
1Rabøl et al., 2010
2Weaver et al., 2010
3Sissakos et al., 2009
4Wolf et al., 2010
5Capella et al., 2010
6Deering et al., 2011
7Mann et al., 2006
8Neily et al., 2010

24. TeamSTEPPS® Communication is…
The process by which information is exchanged between individuals, departments, or organizations
The lifeline of the Core Team
Effective when it permeates every aspect of an organization
Assumptions
Fatigue
Distractions
HIPAA

25. Basic Components and Process of Communication
16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.

26. Comprehensive Unit based Safety Program (CUSP)
CUSP & Teamwork
Comprehensive Unit based Safety Program (CUSP)
Educate staff on science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
Teamwork tools:
Call list
Daily goals
AM briefing
Shadowing
Observing rounds
Learning from defects*
TeamSTEPPS®
9/9/2019
Armstrong Institute for Patient Safety and Quality

27. TeamSTEPPS® Standards of Effective Communication
Complete
Communicate all relevant information
Clear
Convey information that is plainly understood
Brief
Communicate the information in a concise manner
Timely
Offer and request information in an appropriate timeframe
Verify authenticity
Validate or acknowledge information

28. TeamSTEPPS® Communication Challenges
Language barrier
Distractions
Physical proximity
Personalities
Workload
Varying communication styles
Conflict
Lack of information verification
Shift change
Great Opportunity for Quality and Safety

29. TeamSTEPPS® Teamwork Actions
Communicate with team members in a brief, clear, and timely format
Seek information from all available sources
Verify and share information
Practice communication tools and strategies daily (SBAR, call-out, check-back, handoff)

30. Teams Make Wise Decisions When There is Diverse and Independent Input
Wisdom of Crowds
Alternate between convergent and divergent thinking
Get from the dance floor to the balcony level
18. Heifetz R, Leadership Without Easy Answers,1994.

31. Recap
Develop lenses to see systems
Work to standardize one process
Infuse these principles of standardization and independent checks in other processes

32. Works Consulted
McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348 (26):
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29-34.
Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 23: ,1995.
Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse events in medical care. Lancet. 349: ,1997.
Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Acad Pr; 1999.
Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, PHR.122: ,2007.
Ending Health Care-Associated Infections, AHRQ, Rockville,MD,
Pronovost P, Wu A, Sexton J, 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):
Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000.
Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998; 316: 1154–7.
Pronovost P, Angus D, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):
Pronovost P, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective clinical practice: ECP. 2001;4(5):

33. Works Consulted
Pronovost P, Jenckes M, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7.
Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations Boeing News Releases/Statements. July Aviation Safety Boeing Commercial Airplanes, Web. 21 Jan <
Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006;355(26):
Dayton E, Henriksen K. Communication Failure: Basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007; 33(1):
Needham D, Thompson D, Holzmueller C, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32:
Heifetz R, Leadership Without Easy Answers, President and Fellows of Harvard College,1994.

34. Armstrong Institute for Patient Safety and Quality
Armstrong Institute for Patient Safety and Quality