Certified Professional in Healthcare Quality (CPHQ)

Chapter Review Chapter 5: Patient Safety

September 20th 2017

Presented By: Shanelle Van Dyke

Objectives

Chapter 5: Patient Safety

1. Recognize patient safety goals and priorities.

2. Identify the role of technology in patient safety.

3. Identify the quality professional’s role in assisting with implementing patient safety activities.

2

Patient Safety Goals & Priorities

3

Medical Error Example

18-month-old Josie King was recovering from 2nd

degree burns when a communication breakdown caused

a deadly misstep. As her mother watched, a nurse gave

Josie a methadone injection despite verbal orders to

the contrary and while assuring her mother that the

order had been changed. Josie went into cardiac arrest

and died two days later.

IHI Josie King Video Clip –

http://www.ihi.org/education/IHIOpenSchool/resources/

Pages/Activities/WhatHappenedtoJosieKing.aspx4

National Patient Safety Goals

National Patient Safety Goals (NPSGs) developed by The Joint

Commission (TJC) for the nearly 15,000 national healthcare

organizations and programs.

5

Polling Question(s)Question #1, #2, #3, and #4

6

National Quality Foundation (NQF)

National Quality Foundation (NQF) established 34 safety practices

Leapfrog Group uses NQF safety standards and identified 4 leaps

for hospitals:

1. Computerized physician order entry

2. Evidence-based hospital referral

3. Intensive care unit physician staffing

4. Safe practices score

7

Patient Safety Practices Agency for Healthcare Research and Quality (AHRQ)

Patient Safety Organization (PSO)

World Health Organization (WHO) Clean Hands Global

Campaign

Institute for Healthcare Improvement (IHI) and

initiatives such as Partnering with Patients for Safety

The National Committee for Quality Assurance (NCQA)

key strategic programs and initiatives such as their

Healthcare Effectiveness Data and Information Set

(HEDIS) performance measurement tool 8

Create a Safety Culture

Have a clear vision of culture required

Assess where organization is compared to its stated values and

goals

AHRQ free patient safety culture survey for hospitals, medical offices,

nursing homes, and pharmacy

Identifies and measures conditions that lead to adverse events and

patient harm

Recognize that leadership owns the culture, whether leaders want

to or not

Create tools to reinforce the behavior and culture desired

Link culture and annual performance review9

Leadership Support for Safety

Allocate resources (staff, equipment, time)

Analyze processes with failures and risks driving change

Communicate and implement changes

Support non-punitive error reporting

10

Fair & Just Culture Everyone makes mistakes and implements workarounds. Emphasize

the importance of learning from mistakes and near misses.

Individuals are accountable to the system. The greatest error is to not report a mistake, preventing the system/others from learning.

Watch for even small, inconsequential errors as they may be a symptom that something is wrong.

If new techniques are being implemented, be sure that everyone understands their roles and questions assumptions.

If a mistake is made, take steps promptly to remedy the situation.

During organizational meetings emphasize that safety is everyone’s responsibility.

A culture of patient safety is created when everyone advocates for safety.

11

Investigating Medical Errors

Focus on issues or error, not outcome

Collect information from practitioners involved

Review Information

Interpret error (intentional or unintentional)

Identify contributing factors (e.g. process issues)

Conduct a full analysis

May need to analyze the root cause depending on the medical

error

Determine next steps needed such as coaching or training12

Approaches to Improve Patient Safety

Improve:

Medication practices

Emergency services

Workplace safety

Reduce healthcare associated infections (HAIs)

Involve patient/family

13

Eliminate Medical Errors

Ensure patients are treated in a safe environment

Work with others to identify potential and actual errors

Facilitate a change process to address errors

Conduct a thorough analysis of where and how patients are at risk

Integrate Risk Management

14

Types of Quality Issues

15

Patient Safety Program Led by Patient Safety Officer Linked to Strategic Plan, Quality Management, Risk Management,

Information Management, and Infection Control Includes safety education for staff, practitioners, and leaders for

orientation and ongoing Includes safety education for patients and family at admission and

as needed Includes safety data collection and analysis:

Incident Reporting

Medical Error Reporting

Infection Surveillance

Facility Safety Surveillance

Staff, practitioners, patient and family perceptions of patient safety and suggestions for improvement

Staff willingness to report errors16

Patient Safety Program continued…

Conducts proactive risk reduction

Identifies high-risk processes

Identifies, manages, and reports sentinel events: an adverse outcome identified that involves death, or serious physical or psychological injury

Requires reporting of results to:

Patient Safety Program and organization’s Safety Committee

Organization staff

Quality Council, executive leadership, governing body, and medical staff leaders

17

Polling Question(s)Question #5, #6, #7, #8, #9, and #10

18

Patient Safety Organization Improvements

Increase feedback and direct communication.

Emphasize teamwork and crew resource management.

Drive out fear of reporting (Just Culture).

Solidify leadership and practitioner commitment/patient safety culture.

Provide training programs for practitioners and staff.

Make environmental adjustments.

Adjust work schedules.19

Internal & External Reporting

Allows lessons to be shared so others can avoid the same mishaps.

Can lead to improved safety.

Sends alerts about new hazards generated to all involved.

Allows sharing of information about experience of individuals

institutions in using new methods to prevent errors.

Reveals trends and hazards that require attention and leads to

recommended best practices.

20

Role of Technology

21

22

Polling Question(s)Question #11, #12, and #13

23

Analysis ToolsThere are two types of analysis tools that can help to mitigate issues such as the ones that result with technology advances.

Failure Mode and Effects Analysis (FMEA)

Root Cause Analysis (RCA)

24

Failure Mode & Effects Analysis (FMEA)

Systematic and proactive method of identifying and preventing failures before they occur

Used for new system/process, redesign of system/process in early stages, and existing systems/processes

Analysis completed for each failure identified (known or potential)

Resources:

http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.

aspx

https://www.patientsafety.va.gov/docs/hfmea/FMEA2.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/downloads/GuidanceForFMEA.pdf 25

FMEA Steps

26

1. Define the topic and process to be studied

Work with your leaders to define the topic of FMEA along with a clear definition of the process to be studied.

For example, FMEA for intravenous admixtures from order entry to completion of admixture preparation.

2. Convene interdisciplinary team with content and process experts

This team should include representatives from each department that is involved in the process including subject matter experts.

3. Develop flow diagram of process and sub-processes

Create a flow diagram and consecutively number each process step.

FMEA Steps Continued…

27

4. List all possible failure modes of each sub-process

For each process step list all possible failure modes. This includes anything that can go wrong that would prevent the process step from being carried out.

Consecutive number the failure modes and list all possible effects for each one.

Determine the severity of each effect.

Determine potential causes (there may be multiple causes)

Determine the probability of occurrence for each of the potential causes.

Determine a hazard score.

Decide with failure modes require additional action.

Record the corrective action

FMEA Steps Continued…

28

5. Determine action for each failure mode to eliminate, control, or accept

Identify an action plan for each failure mode that will be corrected. There are often multiple actions, and these can be used multiple times in the process. Solicit input from the process owners if they are not on the team. If possible, conduct a pilot or trial run before facility-wide implementation.

6. Identify corresponding outcome measure to test the redesigned process

Identify the measures that will be used to analyze and test the redesigned process, and identify the person responsible for completing the action.

29

Root Cause Analysis (RCA)

Systematic process aimed at finding the basic problem (root cause) and taking action to correct the problem after it has occurred.

Must be identified when variation is inherent in process and reducing variation is desired

Requirement of TJC in response to a sentinel event (see website for format)

Other accrediting organizations may also use a root cause analysis process

30

RCA Process

Process includes:

Identify potential causes of variation.

Verify potential causes by collecting data about the process –

what was supposed to happen vs. what did.

Analyze data utilizing tools to determine actual causes or most

probable causes.

Develop and implement action plan to eliminate or minimize

the root cause of the variation. 31

RCA Factors

32

Implementing Patient Safety Activities

33

Quality’s Role in Patient Safety

34

Patient Safety Event Examples

35

Polling Question(s)Question #14, #15, #16, and #17

36

Progress CheckEnd of Chapter Review Questions

37

38

ANSWER KEY