Download presentation
Presentation is loading. Please wait.
1
Checklists, Protocols, and Patient Safety
James P. Bagian, MD, PE Chief Patient Safety and Systems Innovation Officer Director, Center for Health Engineering & Patient Safety University of Michigan
2
It’s Not Rocket Science University of Michigan
Checklists, Protocols, and Patient Safety It’s Not Rocket Science James P. Bagian, M.D., P.E. University of Michigan
3
Overview Problem Contributing Factors Programmatic Components
Specific Examples Opportunities
4
Patient Safety - The Problem
Not New 4
6
Medicare – Adverse Events 2010
13.5% Adverse Events (Serious Events) 13.5% Temporary Harm 1.5% die (15,000/month ~ 180,000/yr) Bottomline – The Problem Is Still Here
7
Where Healthcare Was/Is
Cottage Industry Mentality Virtually Total Reliance on: Professional/Individual Responsibility Individual Perfection Train and Blame Little Understanding of Systems Relative to People and Processes Ignorance vs Arrogance Culturally Different!!!! 7
8
Program Elements Goal –
9
Program Elements Goal – Prevent Inadvertent Harm To Patient While Under Our Care
10
Program Elements Goal – Prevent Inadvertent Harm To Patient While Under Our Care Culture Not Compliance Identify Barriers Reporting Systems
12
Combating Shame: Blameworthy Concept
Safety Reports Only For Systems Improvement Safety Report Kept Confidential/Nonpunitive As Long As Not Deemed ‘Intentionally Unsafe’ Criminal Act Under Influence of Alcohol or Illicit Drugs Purposely Unsafe Supervisory System Is A Parallel Process May Not Use Identified Info From Safety Report
13
Patient Safety System Design
THE "MISHAP DIAMOND" Weak Program Model Severity Frequency Type A Type C Type B Incidents Close Calls 13
14
Patient Safety System Design
THE "MISHAP PYRAMID" Strong Program Model Frequency Severity Type A Type C Type B Incidents Close Calls 14
15
Program Elements Goal – Prevent Inadvertent Harm To Patient While Under Our Care Culture Not Compliance Identify Barriers Reporting Systems Systems-based Solutions
16
Safety & Human Error: Cornerstones
People Don’t Come to Work to Hurt Someone or Make a Mistake Must Keep Asking “Why?” 16
17
Safety – Human Error Hindsight Bias
Use the Forklift Analogy The A320 story Look for True Cause 17
18
Causation/Actions: Who vs.What &Why
Action focused on correcting individual
21
21
22
Behavior Response When I say “UP”, everyone raise your hand AND slap it back down as quickly as you can Do 4 or 5 times. Hit table the same time. Last time only hit table (some will raise hands). 22
23
This Was Not An Aerobic Exercise
Demonstrates: “paired associate learning” Pattern recognition. Taking shortcuts. Do we have any systems where we do repetitive actions that might have more than one action? Demonstrates a low level brain response. Training yields a low level auto response, telling someone not to do something under these conditions won’t be effective. 23
24
Causation/Actions: Who vs.What &Why
‘Whose Fault Is This?’ Actions focused on correcting individual ‘Corrects’ only after problem occurs Limited scope of action and generalizability What & Why Actions focus on systems level causation Widespread applicability Stronger preventive strategy 24
25
Operating Room
26
How Did We Do? - VA Neily et al. Incorrect Surgical Procedures …Arch Surg 2009 Nov;144(11):
27
VA –
28
What Did We Learn? - VA Incorrect Surgery Associated With Noncompliance Actions needed well before entering OR Timeout period is too late in many cases Systems-based approaches beyond individual Involvement of all disciplines Structured communication that drives discussion – Medical Team Training (MTT) -Briefings & Debriefings –
29
VHA NCPS Medical Team Training Program 2005 -2010
170 Facilities 193 Learning Sessions 13,882 VHA Staff MTT Medical Team Training JULY 2010 Mean = 74 Attendees Per Learning Session Largest One Day Session = 208 (Baltimore, MD Jan 14, 2010) Largest Facility Attendance = 356 (Dallas, TX December 9-11, 2008) 29
30
Communication Communication Identified As Principal Factor >70% Of RCAs Medical Team Training (MTT) Developed To Improve Results Crew Resource Management Principles AND Briefings and De-Briefings
31
Supporting Long Term Memory
Checklists Put knowledge in the world vs. in the head Recognition is better than recall Tool to Guide and Improve Communication Checklist Philosophy “Read and Verify” checklists “Read and Do” checklists 31
32
IV Insertion Checklist
Before Insertion Patient Identification……………………………..CONFIRMED Correct Side………………………………………CONFIRMED Catheter Size……………………………………..CONFIRMED Equipment…………………………………………AT BEDSIDE Patient……………………………………………..BRIEFED After Insertion Tourniquet…………………………………………REMOVED Line………………………………………………...FLUSHED Pump……………………………………………….SET (with fluids) Sharps………………………………………………DISPOSED Site…………………………………………………..LABELED Documentation…………………………………….COMPLETE 32
33
Why Do a Briefing? Establish a platform for common understanding
Gives people permission to be frank & honest Gets everyone on the same page Provides a structure for collaborative planning Creates a shared mental model Briefings help team members form a shared mental model…to get on the same sheet of music. Briefings are a way of acknowledging every team member and the perspective / knowledge they bring to the group. Briefings provide the team leader with ALL the information needed to make the best decision or plan. *Comparing flight crew pre-brief (eg. What if there is bad weather or what if we lose an engine, etc? What do you do? What do I do?) If these people who don’t know each other should brief, why shouldn’t OR teams brief? Briefings helps each team member form a shared mental model – each knowing what to expect, who will be doing what, what the contingency plans will be, etc. 33
34
Briefings Dialogue among principals using concise, relevant information to promote clear and effective communication - Real time - Face-to-face - All team members present - All team members participate A briefing offers the structure and format for a dialog to occur! It is a discussion – not a one-way report or presentation. It is intentional and focused – a review of very specific issues such as reviewing timelines, goals, and/or contingency plans. 34
35
OR Policy Changed to Require Attending Surgeon in OR
36
Checklist-Driven Pre-Op Briefing
37
Asking the Right Question
“Any questions?” VS “What is your biggest concern for today?”
39
Post-Op Debriefing Attending surgeon Anesthesiologist/CRNA Circulator
Entire Surgical Team Attending surgeon Anesthesiologist/CRNA Circulator Scrub nurse/tech Resident, PA, perfusionist, others Guided by checklist (specialty specific) What went well? What did not go well? What did we learn? What can we do to improve our processes? Timing – when patient is stable before attending leaves (update prior to patient leaving OR) Method to track debrief items and follow-up: UH Leadership Group 39
40
Post-Op Debriefing What it is NOT: What it IS:
Chance to whine about people Chance to collect statistics for statistics sake What it IS: Tool to identify problems that impact patient care Tool to solve problems as a team
41
Checklist-Driven Post-Op Debriefing
44
Medical Team Training Safety Attitudes Questionnaire
* * In this clinical area, it is easy to speak up. I would feel safe being a patient here. * P < 0.05 paired, Students t-test N = 3138 Questionnaires
45
Nursing Turnover P = 0.02 45 Operating Rooms and 35 Intensive Care Units Pre = 12 Months Prior to Learning Session Post = 12 Months Following Learning Session
46
Outcomes – Morbidity / Mortality
Observed / Expected Mortality Ratios P = 0.03 As teams gain experience with the preoperative briefing guided by a checklist (MTT exposure) the adjusted surgical morbidity and mortality in that facility decreases significantly. Quarters of MTT 46
48
VA – vs Reported Adverse Events dramatically reduced Reported Close Calls increased
49
VA –
50
MTT – Facility Level Impact
67% High Impact on OR Staff 73% High Impact on OR Patients 69% of OR Teams Improved Teamwork 66% of OR Teams Report Improved Efficiency Eqpt Util (61%), Starts (35%), Duration (19%) Safety Attitudes Questionnaire (SAQ) Significant Improvement (p<0.001): Working Conditions, Perception of Mgmt, Job Satisfaction, Safety Climate, & Teamwork
51
Neily et al. Assoc. Between MTT and Surg Mortality. JAMA
53
MTT Impact - VA N=108 Institutions; 74 MTT, 34 Control
MTT 50% greater decrease in mortality & morbidity than Control Dose-response – 0.5 deaths/1000 procedures less per quarter p=0.001 0.6 deaths/1000 procedures per increase in briefing/debriefing p=0.001 70% Reduction in reported OR related harm
54
Summary – Gaps & Opportunities
Systems Approach – Surgical issues must be dealt with in the extended peri-operative period, not solely in the OR Entire System of care must be Examined and Engineered with desired results in mind – avoid unintended consequences Team Training – start in initial training & sustain More than SBAR – Leadership Must Be Involved Checklist-guided briefings and debriefings Can’t rely on individuals being careful (vigilant) Compliance – Trust But Verify Consequences for Deliberate Non-Compliance
55
Conclusions Starting At The Top, Assure Staff At All Levels Possess Competence Regarding Formulating Appropriate Causal Statements Creating Corrective Plans With Systems-Based Actions Basic Human Factors Engineering Concepts Team and Communication Skills Implement Tools That Emphasize High Quality, Safe Patient Care Is First Priority (e.g.- MTT) Create System To Reinforce & Reward Concept That Quality and Safety Are Everyone's Job
56
It’s Not Rocket Science
Move From: Resistance It’s Not Rocket Science Pro forma Compliance True Cultural Adoption
57
In Perspective - Einstein
Problems – “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” “Insanity: doing the same thing over and over again and expecting different results” Value – “Not everything that can be counted counts, and not everything that counts can be counted.” 57
58
In Perspective - Goethe
“Knowing is not enough; we must apply. Willing is not enough; we must do." 58
59
In Perspective - Meade “Never doubt that a small group of thoughtful committed people can change the world; indeed it’s the only thing that ever has!” 59
Similar presentations
© 2025 SlidePlayer.com Inc.
All rights reserved.