Danger Will Robinson!wisha-training.lni.wa.gov/.../UWSchoolOfMedicine/... · Occupational...
Transcript of Danger Will Robinson!wisha-training.lni.wa.gov/.../UWSchoolOfMedicine/... · Occupational...
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Identify High Risk PPE-Related Occupational Activities
Danger Will Robinson!
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Disclosure • Funding and support for this project has
been provided by the State of Washington, Department of Labor & Industries, Safety & Health Investment Projects
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Overview • Introductions • Foundational knowledge
• What is a “failure modes and effects analysis” • Value of simulation • Why is it useful • What are “best practices” in simulation design to
identify risk • Small group work and JIT trainig • Take home info and skills
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Faculty
• Ross Ehrmantraut, BSN
• Sarah H. Parker, PhD
University of Washington Division of Emergency Medicine
UW Institute for Simulation and Interprofessional Studies
Virginia Tech University
• Rosemarie Fernandez, MD • Steve H. Mitchell, MD
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Introduction / Tables
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What is an FMEA • Risk assessment tool used in many high
risk industries • Proactive- Identifies possible ways a
product, service or process can fail • Prioritizes the actions to reduce future
failures
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When to use an FMEA? • Designing new systems, products
processes • Exposes problems that may result in safety
hazard, malfunction, workload issues • Changing existing systems, products,
processes • Improve existing operational processes by
identifying problem states
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HOW EXACTLY CAN SIMULATION HELP?
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Advantages of Simulation
• Simulate routine events under non-routine conditions
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Advantages of Simulation
• Simulate non-routine clinical events
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• Understand potential risks of new therapies / protocols
Advantages of Simulation
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Advantages of Simulation
• Deliberate
• Replicable
• Standardized setting
• Allows for direct observation
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Event-based Simulation Design
• Event = substantive task with a clear beginning and ending
• Trigger = standardized, scenario-specific indicators embedded in the scenario, designed to force a transition between events
Patient Refuses Medication
Escalates To Threat Negotiation
Participants called to
patient bedside
Patient demands to
be discharged
Patient recants desire to leave
Patient called to
Xray
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Event-based Simulation Design
Event Tr Tr S Event Event
Event
Event Tr
Tr
Event
Event
Tr
Tr
Fowlkes J, Dwyer DJ, Oser RL, Salas E: Event-‐based approach to training (EBAT). Int J Aviat Psychol 1998, 8(3):209-‐221.
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Safety & Health Investment Projects
Personal Protective Equipment Training for Health Care Workers Treating Patients with
Highly Contagious Infectious Diseases
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Goals • Identify high risk processes associated
with providing care while wearing high level PPE
• Develop an in-depth understanding of the challenges associated with providing care to a patient with copious watery, infectious stool
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Clinical Focus • Provision of hygienic care
• Linen change • Cleaning patient
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Objectives 1. Identify the risks (safety threats) associated
with specific steps of this process 2. Identify PPE-related risks 3. Identify solutions to the most common or
most critical safety threats 4. Use data to inform the development of a
Just-in-Time app
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Methods • Simulated process with multiple care
teams • Recorded simulation from multiple views • Executed FMEA
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Hygienic Care Simulation
Prep supplies
Begin First Side
Spill Management S T T Move to
second side T Clean up T E
Event 1 Event 2 Event 3 Event 4 Event 5
Behaviors
• Gather linens • Arrange waste
receptacles • Ensure adequate
disinfectant • Execute pre-brief
• Roll patient • Position devices/
tubes • Remove head/foot • Release fitted sheet • Prepare new linens
• Create barrier on floor
• Discuss fecal management system
• Revisit Event 2
• Ensure supplies duplicated on other side
• Gross contamination check
• Repeat Event 2
• Remove all materials from floor
• Bleach floor • Clean tubing/
equipment
*OBSERVABLE
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Methods • Simulated process with multiple care
teams • Recorded simulation from multiple views • Executed FMEA
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Methods • Simulated process with multiple care
teams • Recorded simulation from multiple views • Executed FMEA
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FMEA Overview
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Terminology • Process • Potential failure mode • Mitigation strategy • Risk Priority Number
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Risk Priority Number • Severity
• 1-10, 10 most severe • What has the most sever impact on a patient
• Occurrence • 1-10, 10 most likely • How likely is it this will occur
• Detectability • 1-10, 10 is least likely to be noticed • How detectible is it, if this occurs?
• RPN= severity*occurrence*detection
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Process Potential Failure Mode
Seve
rity
Occ
urre
nce
Det
ecta
bilit
y
RPN Possible Mitigation Strategy
Set up blankets on floor to dam liquids (do on both sides of bed)
Item not available in close proximity to provider 7 8 3 168 set up/laundry cart on both sides
Becoming contaminated (feet) 1 10 1 10 possible speak aloud? Additional
layer?
becoming contaminated, aprons/gowns too long hitting floor
5 5 8 200 tie it up? Additional layer? Relies on observer.
Spreading agent by kicking towels 4 6 8 192
tripping over towels 10 5 1 50
observer come around? Positioning of observer for each step? (is there an SOP if someone goes down?)
incontinence pads don't stay rolled and only absorbant on one side
4 4 1 16 checklist and procedures for how to dam
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Results • 16 identified failure modes related to EVD
patient hygienic care • 30 discrete steps • same failure mode was often associated with
multiple steps • e.g., provider contamination
• Failure modes ranged in RPN from 6 – 400
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0
10
20
30
40
50
60
01-‐100 101-‐200 201-‐300 301-‐400
SubopHmal
Equipment
Protocol
Checklist / Brief
Low Risk Low – Medium Risk
Risk Priority Number (severity x occurrence x detectability)
Medium – High Risk High Risk
Num
ber o
f Failure M
odes Id
enGfi
ed
SoluGon Type to Address Failure Mode
Results
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SMALL GROUP WORK
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FMEA Overview
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Care of the EVD Patient • Unique issues
• PPE • Critically ill • Teamwork
• Clinical unknowns
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Clinical Focus: Fecal Management
• Placing a fecal management system for an EVD patient
• Change the receptacle bag • Place a clean bag
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FMEA Overview
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Video
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Exercise • Define the steps in the process
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REPORT OUT
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FMEA Overview
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Process Potential Failure Mode Effect of Failure Mode
Set up blankets on floor to dam liquids (do on both sides of bed)
Item not available in close proximity to provider
Procedure takes too long and patient declines
Becoming contaminated (feet) Increased risk of agent spreading
becoming contaminated, aprons/gowns too long hitting floor HCW exposure
Spreading agent by kicking towels HCW exposure
tripping over towels Physical injury and difficulty assisting provider
incontinence pads don't stay rolled and only absorbant on one side
Increased splatter and unrecognized gross contamination
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Exercise • Identify potential failure modes • Identify effects of each failure mode
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REPORT OUT
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FMEA Overview
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Risk Priority Number • Severity
• 1-10, 10 most severe • What has the most sever impact on a patient
• Occurrence • 1-10, 10 most likely • How likely is it this will occur
• Detectability • 1-10, 10 is least likely to be noticed • How detectible is it, if this occurs?
• RPN= severity*occurrence*detection
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Exercise • Calculate risk priority score for each failure
mode
RPN = (severity) x (occurrence) x (detectability)
• Severity (1 = not severe è 10 = most severe)
• Occurrence (1 = rare è 10 = very common)
• Detectability (1 = easily detected è 10 = undetectable)
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Process Potential Failure Mode Effect of Failure Mode
Seve
rity
Occ
urre
nce
Det
ecta
bilit
y
RPN
Set up blankets on floor to dam liquids (do on both sides of bed)
Item not available in close proximity to provider
Procedure takes too long and patient declines 7 8 3 168
Becoming contaminated (feet) Increased risk of agent spreading 1 10 1 10
becoming contaminated, aprons/gowns too long hitting floor HCW exposure 5 5 8 200
Spreading agent by kicking towels HCW exposure 4 6 8 192
tripping over towels Physical injury and difficulty assisting provider 10 5 1 50
incontinence pads don't stay rolled and only absorbant on one side
Increased splatter and unrecognized gross contamination
4 4 1 16
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REPORT OUT
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FMEA Overview
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What Now? • Rules of thumb
• Prioritize highest RPN • If failure has severity of 10, deal with it even if
the overall RPN is low • Mitigation strategies
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Process Potential Failure Mode
Seve
rity
Occ
urre
nce
Det
ecta
bilit
y
RPN Possible Mitigation Strategy
Set up blankets on floor to dam liquids (do on both sides of bed)
Item not available in close proximity to provider 7 8 3 168 set up/laundry cart on both sides
Becoming contaminated (feet) 1 10 1 10 possible speak aloud? Additional
layer?
becoming contaminated, aprons/gowns too long hitting floor
5 5 8 200 tie it up? Additional layer? Relies on observer.
Spreading agent by kicking towels 4 6 8 192
tripping over towels 10 5 1 50
observer come around? Positioning of observer for each step? (is there an SOP if someone goes down?)
incontinence pads don't stay rolled and only absorbant on one side
4 4 1 16 checklist and procedures for how to dam
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Exercise • Determine risk mitigation strategies
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REPORT OUT
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FMEA Overview
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Summary • FMEA is a useful tool for rapidly evaluating
risks of a new process • Event-based simulation allows us to see
the new process in action and develop a more accurate FMEA
• Guidebook contains step by step information
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Thank you
• Washington State Department of Labor & Industries
• Sarah Wolz, MS • Nancy Simcox, MS • Scott (John) Meschke PhD, JD • Bryan Kim, BA
Sponsor Collaborators
• Douglas Franzen, MD • Andrew McCoy, MD • Erin Ehrmantraut, RN • Dayna Morgan, RN, MN • Robin Collier, RN, MN • Brandi Ward, BA
Simulation Participants
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QUESTIONS