# Presentation: 051339

## Patient Safety in Maternal Child Health

- Sheila Warren, MPH, RN, CPHQ
- IHS Patient Safety Consultant
- _[www.ihs.gov](http://www.ihs.gov/)_
- 301-443-9058

##  The IHS Patient Safety Program Priorities

- WebCident Development and Deployment
- Reporting events to learn about risks
- Involvement of all staff to identify risk and proactively adverse events and harm.
- Tort Claim Reform: Protections for Providers
- Full Disclosure P&P
- Patient involvement in self care management
- Development of an IHS Patient Safety Node
- To communicate and spread best practices, provide education and support for IHS/tribal programs.
- Just Culture Initiative Spread
- Learning culture
- Reporting without punishment but with accountability

## Adverse event process to tort claims

- Event Reported
- Event Discovered
- Event Reported
- Notifications to healthcare Ld., RM, staff
- Notification to patients/family
- Evaluation of Event
- Possible Tort claim
- Tort Claim
- Award or Settlement – What then?
- Providers reported to NPDB

## Tort Claim (or adverse event outcome)

- What did we learn from the event?
- Did we fix the process in a way that it would never happen again?
- How did we share this information?
- Area and SU leadership?
- Staff involved?
- Other SUs and Areas?
- To tribes and others who might benefit?
- What happened to our healthcare providers and staff involved?
- Were they supported?
- Reported to NPDB?
- Fired, run off the reservation?

## What did we learn?

-  What is the culture of the organization?
- Non-punitive
- Punitive
- Just

## Did we fix the process so the event would never happen again?

- How was the process evaluated?
- Morbidity and Mortality review
- Peer review
- Root Cause Analysis
- Are Failure Mode Effects Analyses routinely performed?
- Other methods?
- Routine evaluation
- No evaluation

## How did we share the information of how to fix the system?

- To the people involved?
- Local leadership/providers?
- Other SUs
- Other Areas?
- Did we spread lessons learned and best practices discovered or developed?

## Fixing the system (cont)

- Weak fixes
- Write a policy and procedure
- Encourage nurse to use the 5 rights
- Strong fixes
- Double checks,
- redundant systems, backups
- Developed barriers or ways to catch the error
- Reminders
- Check sheets
- Stronger fixes
- Re-engineered the system so the event could not happen again
- Reconstruction
- Electronic health record implementation
- Gas connections
- Tubing connections

## What happened to our providers and staff?

- Were they supported?  How?
- Punitive Actions?
- Fired?

## The Just Culture

- To err is human
- To drift is human
- Risk is everywhere
- We must manage in support of our values
- We are all accountable
- Source:  “Patient Safety and the Just Culture”.  Outcome Engineering, LLC, David Marks and Scott Griffith.

## Just Culture

- Duty to avoid Causing Unjustifiable Risk or Harm.
- Duty to Follow a Procedural Rule
- Duty to Produce an Outcome

## Just Culture Algorithm

- Human Behavior
- At Risk Behavior
- Reckless Behavior

## The Just Culture – not punitive not blame free

- Create a Learning Culture: To understand risk, behavioral choices and learn from mistakes.
- Open, Fair and Just:  Be accountable but not overly punitive
- Design Safe Systems:  Don’t focus on human error or unintended consequences but on quality decisions and design of safe systems.
- Our systems should anticipate human errors and permit recovery when errors do reach patients.
- Managing Behavioral Choices:  Ask every healthcare provider to continuously evaluate the risks inherent in the choices they make.  Avoid “Drift”.
- Source:  “Patient Safety and the Just Culture”.  Outcome Engineering, LLC, David Marks and Scott Griffith.

## What is coming down the Pike?

- Patient Safety Organizations
- Reporting without punishment
- Much more involvement in Patient Self Care management (already started)
- Much more provider, leadership and staff awareness of their own risk practices and involvement in risk identification and reporting.

## Food for thought as you move forward to keep patients safe from harm

- Do you have a just culture at your organization?
- Are you aware of what things you do to create risk for yourself and the patient?
- Is the patient fully participating in their care management?
- When near miss adverse event occur, are they problem-solved?  RCAs,FMEAs?
- Are you reporting near miss and actual adverse events?
- When Adverse event occurs is it solved in a way that it will never happen again?  - Strong fixes?  What are they?
- Are best practices and evidence-based practices used at your organization?
- How do you spread successes and best practices with other IHS and Tribal entities so they can learn?

## Ways to improve patient safety

- Use WebCident and report as much as you can so we can learn about our risks.
- Increase use of FMEA and RCA activities to proactively reduce risk and develop strong fix solutions to prevent adverse events.
- Fully involve patients in their healthcare management.
- Evaluate things that you do to create risk – how do you “drift” away from safe behaviors?
- Join the IHS Patient Safety Node and the IHI 5,000,000 lives campaign
- Adopt a Just Cause Culture for your organization – learn more about this.
- Implement or comply with the Joint Commission National Patient Safety Goals – even if you are not Joint Commission accredited.
- Contact me if you are interested in working on patient safety projects.