# Presentation: 321602

## National Center for Patient Safety

- Patient Safety - Why Bother?

## Patient Safety - Background

- Not a New Problem
- 1964 - Schimmel (Ann. Int. Med.)
- 20% of Univ. Hospital Admissions Injured
- 20% of those serious/fatal
- 1981 - Steel (NEJM)
- 36% of Teaching Hosp. Admissions Injured
- 25% of those serious or life threatening
- >50% medication related

**Notes:**
Ask how many have heard the comment that ‘Why does it always seem that it is the health professional’s family that seems to have the complication?”

## Patient Safety - Background

- 1989 - Gopher (Proc. Human Factors Society)
- 1.7 errors/day/patient (29% pot. serious)
- 1991 - Harvard Practice Study (NEJM)
- NY State in 1984
- 4% of Admissions Injured
- approx. 0.5% fatal overall
- 69% preventable
- normalized to U.S. = 180,000 deaths/yr

## Patient Safety - Background

- Interviews with Family Practice MDs
- >100 MDs
- 2-20 years experience
- approx. 50% committed error resulting in patient death

**Notes:**
Bottom line - Not an Uncommon Experience

## NCPS - Background

- 1997
- National Patient Safety Partnership (NPSP)
- Expert Advisory Panel on Patient Safety System Design
- 1998
- NCPS Announced
- 1999
- NCPS Formed

**Notes:**
VA under Ken Kizer decided to attack this problem

NPSP - consists of AMA, AAMC, AHA, ANA, DoD, JCAHO

Expert Advisory Panel

Kizer wanted the effort to get the level of attention needed and created NCPS.

Reports directly to USH.  Parallels aviation industry to maintain credibility and avoid conflict of interest.

## National Patient Safety Partnership

- Goal & Objectives
- The primary goal of the NPSP is to align the essential elements - people, including patients; processes; and structures -  into a strategic framework that can be applied to reduce untoward consequences of healthcare.

## Expert Advisory Panel On Patient Safety System Design

## Expert Advisory Panel On Patient Safety System Design

- High Reliability Organizations
- Aviation Safety Reporting System
- Genesis
- Characteristics

**Notes:**
TWA #514 at Round Hill in 12/74

ASRS implemented in 4/76

All reporting is voluntary in the final analysis

Value of narratives, expert analysis, feedback, non-punitive

## Expert Advisory Panel On Patient Safety System Design

- NASA/JSC Close Call Reporting
- Risk Management - focuses on Preventive Action that is taken to eliminate causes of potential nonconformity, defect, or other undesirable situation in order to prevent occurrence.

**Notes:**
NASA didn’t practice what they preached in the spaceflight arena in their day to day work!!

## Expert Advisory Panel On Patient Safety System Design

- NASA/JSC Close Call Reporting
- Six Major Steps
- Assess
- Analyze Hazard Controls
- Permanent Over Temp.; Physical Over Procedural
- Request Funding - Coordination
- Funding
- Implementation
- Eliminate/Control/Accept (Accepted Reviewed Cont.)
- Closure - Tracking System

## Expert Advisory Panel On Patient Safety System Design

- NASA/JSC Close Call Reporting
- Reporting Methods
- Paper
- JSC Safety Action Hotline
- Center Director Hotline
- NASA HQ
- NSRS
- OSHA

**Notes:**
Take any report you can get!!

## Expert Advisory Panel On Patient Safety System Design

## Expert Advisory Panel On Patient Safety System Design

## Expert Advisory Panel On Patient Safety System Design

- 600

- 300

- 0

- 1994

- 1998

## Expert Advisory Panel On Patient Safety System Design

- 1.0

- 0

- 1994

- 1997

## Expert Advisory Panel On Patient Safety System Design

- Procedure Changes
- Or Inspections
- 15%

- Training, Counseling or Increased Awareness
- 26%

- Further Study or No Action Needed
- 8%

- Modifications/Repairs
- 51%

## Expert Advisory Panel On Patient Safety System Design

- Corrective Actions for Close Call Reports
- Modifications or Repairs - 51%
- Training, Counseling, or Awareness - 26%
- Procedure Changes or Inspections - 15%
- Further Study or Action Needed - 8%

## Expert Advisory Panel On Patient Safety System Design

## Expert Advisory Panel On Patient Safety System Design

## Expert Advisory Panel On Patient Safety System Design

- Summary of Findings And Recommendations
- Establish a Voluntary Reporting System
- Confidential and De-identified
- Non-punitive
- Reports Should Emphasize Narratives
- Interdisciplinary Review Teams
- About Identifying Vulnerabilities NOT Statistics

**Notes:**
All reporting -  is in the end - voluntary

## Expert Advisory Panel On Patient Safety System Design

- Summary of Findings And Recommendations (Cont.)
- Prompt Feedback
- Open to All Comers

**Notes:**
Feedback lets the reporters know that their report didn’t end up in a “Black Hole”

It also can verify that you addressed the proper problem and have a solution that makes sense

## Patient Safety - Human Error

- Medicine Views Errors as Failings Which Deserve Blame - Fault
- Train and Blame Mentality
- Nursing Emphasizes Rules
- Medicine Emphasizes Knowledge
- Corrective Actions Focus on Individual
- No Blood No Foul Philosophy

## Patient Safety - Human Error

- People Don’t Come to Work to Hurt Someone or Make a Mistake
- Systems vs. Individual Fault/Problem
- Must Keep Asking “Why?”

## Patient Safety - Human Error

**Notes:**
Latent Errors
	Design
	Training
	Procedures
	Reliance on Memory
	Standardization
	Fatigue

## Patient Safety - Human Error

**Notes:**
Use the Forklift Analogy

The A320 story

Look for True Cause

## Patient Safety - Attitudes re Error

- Only 27% Agreed that Errors were a Serious Problem
- 70% Feel People Aren’t Punished
- 49% “Ashamed” by Error
- 4% Lose Respect for Others Who Err
- 31% are Told About Errors
- More likely to Report Own Errors

## Patient Safety - Human ErrorProcess Design & Organizational Change

- Process Design
- Reduce Reliance on Memory & Vigilance
- Simplify
- Standardize
- Checklists
- Forcing Functions
- Eliminate Look and Sound-alikes

- Organizational
- Increase Feedback
- Teamwork
- Drive Out Fear
- Leadership Commitment
- Improve Direct Communication

## Patient Safety - Needs

- Reporting System
- Encourage More and Accurate Reports
- Need to Remove Fear and Demo Benefit
- Acceptance of Systems Approach
- Appropriate View of Blameworthy Behavior

**Notes:**
It’s hard to correct a problem if you don’t know what it is.

Mention the approach to AI’s in the new  Handbook.
	Illegal
	Intentionally unsafe act
	Substance Abuse
	Alleged Patient Abuse

## Patient Safety - Needs

- Culture Change!!!

**Notes:**
Policies written down aren’t the answer

Mindfulness

ASRS dope smuggler case

McCartney Story - Leaders Set the Tone

Safety is Everyone’s business
The Goal is PERFECTION
If you’re not sure it’s safe it’s not safe!!

## NCPS - Current Activities

- Patient Safety Improvement Handbook
- Safety Assessment Code Prioritization
- Root Cause Analysis Methodology
- JCAHO Coordination
**Operational Roll-Out of PSI Handbook**
- Patient Safety Advisory Oversight Committee (PSIOC)
**VHA Patient Safety Information Systems**
- Safety Awards
- Patient Safety Centers of Inquiry (PSCI)

**Notes:**
JCAHO conversation

SAC advantages
RCA and triage questions
Aggregated Review

Shortcomings in old procedure
Emphasis on prevention not punishment

PSR - tripwire for lessons learned and emerging problems