What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um...
23
What Is Possible In A Hospital? Getting To Zero Harm Cincinnati Children’s Story November 4, 2013 Stephen E. Muething, MD Vice President for Safety James M. Anderson Center
-
Upload
proqualis -
Category
Health & Medicine
-
view
109 -
download
0
description
Apresentação de Stephen Muething durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
Transcript of What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um...
What Is Possible In A Hospital?
Getting To Zero HarmCincinnati Children’s Story
November 4, 2013
Stephen E. Muething, MDVice President for Safety
James M. Anderson Center
SET THE GOAL
ACCEPT THE GAP
CONTINUOUS IMPROVEMENT
Our Safety Goal:
ELIMINATE ALL HARM
Begin With Serious Harm
Serious
Safety
Events
Serious Preventable
Events
Events of Minimal
to Moderate Harm
Near-Miss Events
Pyramid
of Harm
BeganSituation Awareness
High Reliability Organizations (HROs)
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
Characteristics of
High Reliability Organizations1. Preoccupation with failure
Regarding 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
Serious
Safety
Events
Serious Preventable
Events
Events of Minimal
to Moderate Harm
Near-Miss Events
Pyramid
of Harm
75% Reduction
80% Reduction
0
2
4
6
8
1007
-05
260
0
09-0
5 2
43
3
11-0
5 2
25
4
01-0
6 2
00
2
03-0
6 1
73
4
05-0
6 1
98
3
07-0
6 2
33
2
09-0
6 2
35
5
11-0
6 2
43
2
01-0
7 2
33
0
03-0
7 2
60
4
05-0
7 2
55
6
07-0
7 3
20
7
09-0
7 2
60
3
11-0
7 2
57
4
01-0
8 2
46
4
03-0
8 2
22
4
05-0
8 2
79
2
07-0
8 2
78
6
09-0
8 2
44
7
11-0
8 2
33
5
01-0
9 2
66
7
03-0
9 2
83
5
05-0
9 2
37
0
07-0
9 2
92
4
09-0
9 2
62
5
11-0
9 2
51
4
01-1
0 2
42
1
03-1
0 3
04
5
05-1
0 2
89
2
07-1
0 3
21
4
09-1
0 2
79
0
11-1
0 2
74
1
01-1
1 2
87
1
03-1
1 3
11
1
05-1
1 3
27
4
07-1
1 3
75
6
09-1
1 3
55
2
11-1
1 3
58
3
01-1
2 3
44
4
03-1
2 3
69
5
05-1
2 3
99
4
07-1
2 4
28
3
09-1
2 3
50
4
11-1
2 3
67
4
01-1
3 3
46
2
Infe
ctio
ns
per
100
Pro
ced
ure
Day
s
Month of ProcedureProcedure Days
Infections
Surgical Site Infections by Procedure Date (Class I & Class II Combined)
Last Updated 02/14/2013 by K. Simon, Anderson Center for Health Systems Excellence Source: Surgical Safety Database
Q2/05 - Individual Anesthesia Follow-upQ3/05 - Anesth Compensation tied to complianceQ3/05 - Orange ID BraceletsQ4/05 - ABX In-pt ImplementationQ2/06 - CHG Wipes by All ServicesQ3/06 - Bundle Measure for Limited Ortho & Neuro
Desired Direction of
Change
40% Reduction
HIGH
RELIABILITY
CULTURE
Pre-Surgery Time-Out
Huddles
Increase Reporting
Empowering to Stop the Line
Frontline Leaders Owning Harm
Peer
Observation
THANK YOU!
QUESTIONS?
http://www.cincinnatichildrens.org/research/divisions/j/anderson-center/default/
