1. Taking Care of Patients Safely
Pitt County Memorial Hospital

2. Let’s not learn patient safety by accident…
Willie King, age 51 with a history of diabetes, consented to a have a below knee amputation on his right foot. Surgeons amputated is left foot in error.
Prior to surgery, Willie joked with the medical staff, “You know which one it is, don’t you? I don’t want to wake up and find the wrong one gone.”

3. Let’s not learn patient safety by accident…
Joan Faulkner was badly burned in a hospital in North Carolina when a cauterizing tool ignited the oxygen that she was receiving during a routine surgical procedure. Her top lip was burned off, her face, neck and chest suffered 2nd and 3rd degree burns.

4. The Costs of Mistakes
The Institute of Medicine estimates 44,000 to 98,000 deaths occur each year due to medical errors
An additional 100,000 deaths occur each year from hospital-acquired infections, half of which were preventable
Probability of a patient dying in a hospital due to an human error is 1 in 300.

5. These types of errors can happen at any hospital!

6. Learning About Human Error

7. From Managing the Risks of Organizational Accidents, James Reason
Why Do Events Happen?
Sometimes an error occurs, but an event or injury is prevented by an internal system of checks
Significant
events or
injuries
Sometimes multiple errors line up to allow a significant event or injury to occur
From Managing the Risks of Organizational Accidents, James Reason

8. Human Error Classification
There are 3 major categories of errors
Skill-based errors
Rule-based errors
Knowledge-based errors

9. Human Error Classification
Skill-Based Errors
Errors made when performing acts or tasks while utilizing skills on “auto-pilot”
Skill-based errors most often occur during lapses in attention (e.g. when we’re pressed for time, or when the action is so routine we don’t pay attention).

10. Human Error Classification
Rule-Based Errors
Errors made when performing acts or tasks that require application of rules accumulated through experience and training
Types of Rule-Based Errors
Wrong Rule
Misapplication of Correct Rule
Non-Compliance with Rule

11. Human Error Classification
Knowledge-Based Errors
Errors made when performing acts related to new or unfamiliar situations that require problem solving or when a rule does not exist or is unknown to the performer
Types of Knowledge-Based Errors
Decision-making
Problem solving

12. Behavior Based Expectations & Tools to Assist in the Reduction of Errors

13. Behaviors for Physicians
1. Pay Attention to Detail
Self-check using STAR
2. Communicate Clearly
Repeat-back
Clarifying questions
Phonetic/numeric clarification
SBAR
3. Handoff Effectively
4. Support Each Other
Speak-Up/Listen using AAA
Encourage questions

14. BBE #1: Pay Attention to Detail
Focus attention to always think before we act.
Why should we do this?
To avoid unintended slips or lapses
To reduce the chance that we’ll make an error when we’re under time pressure or stress
When should we do this?
Before we act, speak, and document

15. Error Prevention Tool Self Checking Using STAR
Stop:
Think:
Act:
Review:
Pause for 1 to 2 seconds to focus on what you’re about to do
Think about what you’re about to do – focus on the action
Concentrate and perform the task
Check to see if the task was done right

16. BBE #2: Communicate Clearly
Communicate correct information in a timely and appropriate manner.
Why should we do this?
To ensure that we hear things correctly and that we understand things correctly
To prevent avoid wrong assumptions and misunderstandings that could cause us to make wrong decisions
When should we do this?
Whenever we communicate information – either in person or over the phone – that could affect the care and safety of a resident or an employee

17. Error Prevention Tool 3-Way Repeat Backs
When information is transferred... 1 2 3
Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear and concise format.
Receiver acknowledges receipt by a repeat-back of the order, request, or information.
Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication.

18. Error Prevention Tool Clarifying Questions
Ask 1 to 2 clarifying questions
When in high risk situations
When information is incomplete
When information is ambiguous
WHY: To reduce the probability of making a wrong assumption. Asking clarifying questions reduces the risk by 2 1/2 times!!
HOW: Phrase your clarifying questions in a positive way and in a manner that will get an answer that improves your understanding of the information

19. Error Prevention Tool Phonetic Clarifications
letter followed by a word that begins with the letter. For example:
For sound alike words, say the letter followed by a word that begins with the letter. For example:
A Alpha
B Bravo
C Charlie
D Delta
E Echo
F Foxtrot
G Golf
H Hotel
I India
S Sierra
T Tango
U Uniform
V Victor
W Whiskey
X X-Ray
Y Yankee
Z Zulu
J Juliet
K Kilo
L Lima
M Mike
N November
O Oscar
P Papa
Q Quebec
R Romeo

20. Error Prevention Tool Numeric Clarifications
For sound alike numbers, say the number and then speak each digit of the number. For example:
15…that’s one-five
50…that’s five-zero

21. BBE #3: Handoff Effectively
Handoff patients or tasks by giving appropriate information and ensuring understanding and ownership.
Why do we have this behavior?
To ensure that complete and accurate information about the patient, project, or task is communicated when responsibility transfers from one individual to another
When should we practice this behavior?
When turning responsibility for a patient, project, or task to another individual

22. Error Prevention Tool SBAR for an Effective Handoff
When transitioning care to another physician, or when requesting a consult on a patient, use the SBAR technique to organize your communication
Situation: Describe the situation, patient or question
Background: Highlight the important information, precautions, issues
Assessment: Outline your read of the situation, problems and precautions
Recommendation: State your recommendation, request or plan

23. BBE #4: Support Each Other
Speak Up for Safety by using the Triple A technique
Ask (Do you think we should order a CXR?)
Advocate (I think we need to order a CXR.)
Assert (I’m concerned that we may miss something if we don’t get a CXR.)
Tips
Use the lightest touch possible…
When asserting, use the safe word: “concern”
If not successful and you’re still worried, then use chain of command

24. Encourage Questions
Encourage questions by inviting questions and positively reinforcing questions when asked.
Asking a question is an emotional security issue. Foster a culture of critical thinking by encouraging questions. Invite questions, and use positive reinforcement when questions are asked.
Top 3 Statements to Encourage Critical Thinking1
“What do you think?”
“That is an interesting question”
“Let’s explore this”
1 Rubenfeld, “Critical Thinking Tactics for Nursing”