Improving Patient Safety with Team

Training
Raleigh, North Carolina
WakeMed Health & Hospitals Amar P. Patel, MS, NREMT-P, CFC
Manager, Medical Simulation Center
http://www.wakemed.org/landing.cfm?id=1097&oTopID=616
Although it is a rare occurrence, pilots regularly
rehearse engine failure in simulators. So when
f d ith l it ti h bit t k faced with a real situation habit takes over.
Simulation enables people to train for rare events
that do not occur often in real life that do not occur often, in real life.
~ Sir Liam Donaldson
Objecti es Objectives
Recall the overall risk for medical errors
in the hospital environment and the top p p
10 specific Sentinel Events by type.
Recall the purpose of the 2009 National
Patient Safety Goal.
List the components necessary for an
effective team training program.
List the biggest challenges to
i l ti t t i i implementing team training programs.
O er iew Overview
Risk for medical errors
Top 10 sentinel events Top 10 sentinel events
National Patient Safety Goals
Effective teamtraining Effective team training
Challenges to implementation
All humans make mistakes.
Healthcare workers are human.
Healthcare workers make mistakes Healthcare workers make mistakes.
~ Dr. Meera Kelley
O er ll Risk Overall Risk
Nearly 100,000 people die
annually annually
Fewer then 3% of hospitals have
an electronic drug ordering system an electronic drug ordering system
2003-2008 survey revealed:
- 39% of physicians admitted to at
least 1 medical error.
C f ti t di t - Cause = fatigue, stress, distress,
Top 10 Sentinel Events T p S
http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats12_08.pdf
Definition Definition
Any unanticipated event in a
h lth tti lti i d th healthcare setting resulting in death
or serious physical or psychological
injury to a person or persons, not
related to the natural course of the
patients stress.
~ The J oint Commission
# 10 # 10
Patient death / injury in restraints
196
3.1%
# 9 # 9
Perinatal death / loss of function
197
3.2%
# 8 # 8
Assault / rape / homicide
241
3.9%
# 7 # 7
Unintended retention of foreign body
285
4.6%
# 6 # 6
Patient fall
396
6.3%
# 5 # 5
Delay in treatment
507
8.1%
# 4 # 4
Medication Error
520
8.3%
# 3 # 3
Op / post-op complication
695
11.1%
# 2 # 2
Suicide
752
12%
# 1 # 1
Wrong-site Surgery
837
13.4%
To 10 Sentinel E ents Top 10 Sentinel Events
Event Number of Occurrences
Patient death / injury in restraints 196
Perinatal death / loss of function 197
Assault / rape / homicide 241
Unintendedretention of foreign 285 Unintendedretention of foreign
body
285
Patient fall 396
Delay in treatment 507 Delay in treatment 507
Medicationerror 520
Op / post-op complications 685
Suicide 752
Wrong-site Surgery 837
Uni ers l Protocol Universal Protocol
How can we change this? g
How can we inspire a safer
k l ? workplace?
Americ n Hos it l Associ tion American Hospital Association
http://www.ahaqualitycenter.org/ahaqualitycenter/jsp/home.jsp
Sentinel event settings S g
http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats12_08.pdf
Sentinel E ent Setting Sentinel Event Setting
Location Number of Occurrences
General hospital 4226
Psychiatric hospital 665 y p
Psych unit in general hospital 311
Emergency department 284
Behavioral health facility 281 Behavioral health facility 281
Human Factors
Definition Definition
The science of understanding the
properties of human capability properties of human capability.
~ Elias Porter, Ph.D
Definition Definition
Those elements that influence the
performance of people operating
equipment or systems; they include equipment or systems; they include
behavioral, medical, operational,
task load machine interface and task-load, machine interface and
work environment factors.
T t C d ~ Transport Canada
In healthcare, what can we
t? prevent?
In healthcare, how can we
t ? prevent errors?
Who is responsible? p
Just Routine O er tion Just a Routine Operation
http://vimeo.com/970665
All humans make mistakes.
Healthcare workers are human.
Healthcare workers make mistakes Healthcare workers make mistakes.
~ Dr. Meera Kelley
2009
N ti l P ti t S f t G l National Patient Safety Goal
http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/
2009 NPSG 2009 NPSG
9 categories
- Ambulatory Health Care
- Behavioral Health Care
- Critical Access Hospital
- Disease-specific Care
- Home Care
- Hospital
- Laboratory
- Long-term Care
- Office-based Surgery
Goals evolve yearly 2010 in pre- Goals evolve yearly, 2010 in pre
publication
2009 NPSG 2009 NPSG
Purpose:
- A method by which J CAHO promotes - A method by which J CAHO promotes
and enforces major changes in
patient safety in thousands of p y
participating organizations around
the world.
- Often target very specific areas such
as infections or falls, other times they
h id f have a wider focus.
Effective Team Trainingg
Te m Tr ining 101 Team Training 101
Communication
Multi &Interdisciplinary education Multi- & Interdisciplinary education
Process changes / analysis
Effective debriefing
Object driven education j
Consider developed programs
- TeamSTEPPS (evidence-based TeamSTEPPS (evidence based
teamwork system)
Te mSTEPPS TeamSTEPPS
http://teamstepps.ahrq.gov/
Te m Tr ining 101 Team Training 101
Simulation isnt an option, it is a
MUST MUST.
Scenario designed to meet the
need need
Realistic
1 person is not responsible, the
TEAM is.
What do you need to make
thi ff ti ? this effective?
Australia Department of Defense
M nikins or Simul tors Manikins or Simulators
Could you use a manikin as a
simulator?
Could you use a simulator as a
manikin?
Whats the difference?
Technolog Technology
Equipment
Computer Games Computer Games
Simulator
Learning Management System
How to use it?
When to use it?
What about scenarios?
Scen rio De elo ment Scenario Development
V lid tion Validation
Visual walk-through of scenario
Simulator driven walk through Simulator driven walk-through
Modify
Re-run scenario
Obtain approvals pp
Tr nsl ting Scen rios Translating Scenarios
Through QA/QI find cases
Choose the simulator Choose the simulator
Pick everything in the case file
Develop the scenario
Develop a chart, remove patient p , p
info create your own!
Include X-rays/Labs Include X rays/Labs
Scen rio Scenario
X r X-ray
Progr m Focused Questions Program Focused Questions
What do you believe to be your greatest
strengths? (What cases are you the most
comfortable with? What skills do you
believe you have mastered?)
What do you believe to be your greatest
weakness? (What cases are you the weakness? (What cases are you the
least comfortable with? What skills do
you believe you would like more time to you believe you would like more time to
practice?)
Self E lu tion Self-Evaluation
Please discuss each participants role
and responsibilities in the scenario. p
Please discuss what could have gone g
better as the scenario evolved and
provide suggestions for improvement.
Please discuss what went well and why
you believe it did.
How does simulation impact
ti t f t ? patient safety?
http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/
Challenges g
http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/
The Ch llenge The Challenge
The pitch
The cost The cost
The people
Understanding the potential
The space p
If we teach today the way we were taught y y g
yesterday we aren't preparing students.
~ Anonymous y
We need to replicate in the classroom the
world in which students are living.
~ Anonymous
What gets us in trouble is not what we
don't know. It's what we know that just
ain't so.
~ Mark Twain
Improving Patient Safety with Team Improving Patient Safety with Team
Training
Raleigh, North Carolina
WakeMed Health & Hospitals
Amar P. Patel, MS, NREMT-P, CFC
Manager, Medical Simulation Center