James M. Anderson Center for Health Systems Excellence From Error to Zero! Derek S. Wheeler, MD,...
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ames M. Anderson Center for Health Systems Excellence From Error to Zero! Derek S. Wheeler, MD, FAAP, FCCP, FCCM Associate Patient Safety Officer Cincinnati Children’s Hospital Medical Center Clinical Director, Division of Critical Care Medicine The James M. Anderson Center for Health Systems Excellence Associate Professor of Clinical Pediatrics University of Cincinnati College of Medicine
Transcript of James M. Anderson Center for Health Systems Excellence From Error to Zero! Derek S. Wheeler, MD,...
James M. Anderson Center for Health Systems Excellence
From Error to Zero!
Derek S. Wheeler, MD, FAAP, FCCP, FCCMAssociate Patient Safety Officer
Cincinnati Children’s Hospital Medical Center
Clinical Director, Division of Critical Care Medicine
The James M. Anderson Center for Health Systems Excellence
Associate Professor of Clinical PediatricsUniversity of Cincinnati College of Medicine
• I do not have any disclosures.
• My objectives are the following:
– Recognize the importance of detecting and learning from medical errors
– Understand the importance of safety culture
– Describe how safety culture enhances learning from errors
– Identify how healthcare reform dovetails with the safety culture movement
Disclosures and Objectives
Why the Emphasis on Quality and Safety?
^OECD estimate.
*Differences in methodology.
**Based on 2007 data.
Notes: Amounts in U.S.$ Purchasing Power Parity, see www.oecd.org/std/ppp; includes only countries over $2,500. OECD defines Total Current Expenditures on Health as the sum of expenditures on personal health care, preventive and public health services, and health administration and health insurance; it excludes investment.
Source: Organisation for Economic Co-operation and Development. OECD Health Data 2010, from the SourceOECD Internet subscription database updated October 2010. Copyright OECD 2010, http://www.oecd.org/health/healthdata. Data accessed on 01/06/11.
Why the Emphasis on Quality and Safety?
Per capita spending(2006 U.S. dollars) $3,678 $6,714
Percent GDP(2006)
10.0% 15.3%
Percent Public Finance(2006)
70% 46%
Life Expectancy higher, Infant mortality lower in Canada
Americans are less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines than Canadians.
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
Dollars in Billions:
5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.0% 16.1% 16.2% 16.6% 17.6%
National Health Expenditures and Their Share of Gross Domestic Product, 1960-2009
Why the Emphasis on Quality and Safety?
“You get what you pay for, right?”
“You get what you pay for, right?”
98,000 deaths per year….
Twice the number of U.S. servicemen killed in the entire Viet Nam War
“You get what you pay for, right?”
“Why I Should Care…”
“Why I Should Care…”
Hospital Acquired Condition (HAC):
1. Object left in patient during surgery 2. Air embolism 3. Blood incompatibility 4. Catheter-associated urinary tract infection 5. Pressure ulcer 6. Catheter-associated bloodstream infection 7. Mediastinitis after CABG surgery 8. Fall from bed 9. Manifestations of poor glycemic control 10. Deep venous thrombosis or pulmonary embolism after knee or hip replacement 11. Infection after bariatric surgery 12. Infection after certain orthopedic procedures of spine, shoulder, and elbow
Medicaid will implement the same Nonpayment Rule starting July 1, 2012!
“Why I Should Care…”
“What have we learned?”
Stelfox HT. Qual Saf Health Care 2006; 15:174
Consumers Union Safe Patient Project (2009)
“Based upon our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year”
“In this report, we give the country a failing grade on progress…”
“In terms of patient safety, health care is an adolescent – earnest and enthusiastic, but awkward and uncoordinated.”
Scalise D. Hosp Health Netw 2004; 78:59
“Small but consequential changes…”
“..these efforts are affecting safety at the margin, their overall impact is hard to see…”
Leape LL, Berwick DM. JAMA 2005; 293:2384
“What have we learned?”
Insanity: Doing the same thing over and over again and expecting different results
“If you always do what you have always done, then you'll always have what you've already got…”
“What have we learned?”
“Our Journey Begins…”
Error Prevention TrainingSafety Coach Program
Root Cause Analysis ProgramSimulation Training
Rapid Response System (“Medical Response Team”)
Quality TransformationTransparency
Leadership Engagement/Support
VAP ReductionSSI Reduction
“Codes Outside the ICU”CA-BSI Reduction
Safety Culture
“Our Journey Begins…”
Serious Safety Events
Serious Harm
Events of Minimal to Moderate Harm
Near-Miss Events
“Our Journey Begins…”
SSESurgical Sentinel EventsCA-BSIPreventable Codes Outside ICUVAPCA-UTISSIPressure Ulcer (Grade III, IV)ADE (Level 6-9)Serious FallsPIV Infiltrates
FY 2015 GoalEliminate all Serious Harm!
“Our Journey Begins…”
“How do we get to zero?”
Changing Paradigms
Systems Thinking• We are all human, and yes we make
mistakes!
• Systems factors are at the root of all errors – fix the system and minimize the error!
Bad Apple Theory• People who make mistakes are lazy
and need to work harder!
• Remove poor performers (“bad apples”) and the system will perform better
“What is striking about many accidents is that people were doing exactly the sorts of things they would usually be doing—the things that usually lead to success and safety. . .Accidents are seldom preceded by bizarre behavior.”
Changing Paradigms
“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”
“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong.
The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”
It’s all about culture!
Safety Culture = Learning Culture = Just Culture
“A word about culture”
“If they can do it…”
Assume that no matter what you do, something or someone will fail.
Now, what are you going to do to make sure that everyone stays safe?
Jim Bouey (Boeing)
1950’s2.7 million deaths
(per million takeoffs)
Present< 1 death
(per million takeoffs)
“If they can do it…”
Safety requires a change in Culture
Teamwork
Professionalism
Communication
Conflict observed in 10% flights(resolved in > 80%)
Belief that the “Captain” shouldn’t be questioned< 5% pilots
Sexton JB BMJ 2000; 320:745
Conflict observed in 10% OR cases(resolved in 20%)
Belief that the “Attending” shouldn’t be questioned50% of surgeons
Sexton JB BMJ 2000; 320:745
Creating a Safety Culture
CreateLearning
BuildTransparency
Design forReliability
ManageBehavior
Adapted from David MarxOutcome Engineering LLC
www.outcome-eng.com
Creating a Safety Culture
CreateLearning
BuildTransparency
Design forReliability
ManageBehavior
Adapted from David MarxOutcome Engineering LLC
www.outcome-eng.com
Learn from failures!
Apollo 1Virgil I. “Gus” Grissom, Edward H. White II,
Roger B. Chaffee
“Spaceflight will never tolerate carelessness, incapacity, and neglect. Somewhere, somehow, we screwed up.”
From this day forward, Flight Control will be known by two words: Tough and Competent. Tough means we are forever accountable for what we do or what we fail to do. Competent means we will never take anything for granted.”
“These words are the price of admission to the ranks of Mission Control.”
Gene Kranz
Learn from failures!
Apollo 13James A. Lovell, Jr, John L. Swigert,
Fred W. Haise, Jr
“Failure is not an option.”
Gene Kranz
I’ve missed more than 9000 shots in my career…
I’ve lost almost 300 games…
26 times, I’ve been trusted to take the game winning shot and missed…
I’ve failed over and over and over again in my life…
And that is why I succeed.
Deliberate Practice and the 10-year rule
Expertise requires 10 years or 10,000 hours of deliberate practice
K. Anders Ericsson, The Cambridge Handbook of Expertise and Expert Performance
Performance
Learn from failures!
Amy C. Edmonson, PhDNovartis Professor of Leadership and Management
Harvard Business School
Calif Manage Rev 2003; 45:55
Learn from failures!
Types of Problem-solving:
1.First-order- Worker compensates for the problem by finding a
workaround
2.Second-order- Worker completes task AND finds a solution for the
underlying cause
Amy C. Edmonson, PhDNovartis Professor of Leadership and Management
Harvard Business School
Creating a Safety Culture
CreateLearning
BuildTransparency
Design forReliability
ManageBehavior
Adapted from David MarxOutcome Engineering LLC
www.outcome-eng.com
Creating a Safety Culture
CreateLearning
BuildTransparency
Design forReliability
ManageBehavior
Adapted from David MarxOutcome Engineering LLC
www.outcome-eng.com
Kathleen M. Sutcliffe, MSN, PhD
Karl E. Weick, PhD
High Reliability OrganizationsEnvironment rich with potential for errors
Unforgiving social and political environment
Learning through experimentation difficult
Complex processes
Complex technology
Design for Reliability
1. Preoccupation with failureRegarding small, inconsequential errors as a symptom that something is wrong; finding the half-event
2. Sensitivity to operationsPaying attention to what’s happening on the front-line
3. Reluctance to simplifyEncouraging diversity in experience, perspective, and opinion
4. Commitment to resilienceDeveloping capabilities to detect, contain, and bounce-back from events that do occur
5. Deference to expertisePushing decision making down and around to the person with the most related knowledge and expertise
Design for Reliability
Applied Ergonomics 2010; 41:713
Creating a Safety Culture
CreateLearning
BuildTransparency
Design forReliability
ManageBehavior
Adapted from David MarxOutcome Engineering LLC
www.outcome-eng.com
Manage Behavior
David MarxOutcome Engineering LLC
www.outcome-eng.com
Creating a Safety Culture
CreateLearning
BuildTransparency
Design forReliability
ManageBehavior
Adapted from David MarxOutcome Engineering LLC
www.outcome-eng.com
James M. Anderson Center for Health Systems ExcellenceStephen Muething, MDPatrick Brady, MDUma Kotagal, MBBS, MScJanet Jacob, RN
University of Michigan Ross School of Business Kathleen M. Sutcliffe, MSN, PhD
Children’s Hospital of Akron Mary D. Patterson, MD, MEd
Cincinnati Children’s Center for Simulation and Research Gary L. Geis, MDJohn Whitt, MDTom LeMaster, RN, MSN, MEd, REMT-P, EMSI
University of Cincinnati College of Medicine Amy Bunger, PhD
Applied Decision Science, LLCLaura Militello, MA
Gary A. Klein, PhD
R18 HS020455
MacroCognition, LLC
