Case Studies in Patient Safety: Foundations in Core Competencies

CONSUMERS ADVANCING PATIENT SAFETY

August 2015 Webinar

Welcome

• Dr. Knitasha Washington, FACHE, Executive Director of CAPS

Learning Objectives

• Understand how patient stories can be used to teach Safety Across the Board principles.

• Explore one story and how you can use this and similar stories in the book, Case Studies in Patient Studies: Foundations in Core Competencies, in teaching Safety Across the Board principles.

• Learn how advance training and implementation of neonatal rapid response teams improves quality and safety in maternal and child health.

• Discuss how patients and families may be invited to share stories in a manner that allows their message to be heard by your key stakeholders.

Agenda

1. Helen Haskell – An overview of the book Case Studies in Patient Safety.2. Lisa Morrise – Share, briefly, the story from the book, “The Trial Meant for You: The Lifelong Medical Journey of a Child with a Complex Congenital Condition.”3.Deborah Kilday, MSN – Detail how implementation and training of neonatal rapid response teams works to mitigate issues upon birth of a compromised infant. Discuss the importance of early identification and a team training approach to improve quality and safety in labor and delivery and neonatal emergent needs.4. Developing and using questions to prompt Safety Across the Board DiscussionHelen Haskell and Lisa Morrise and Deborah Kilday –How questions exploring safety issues were developed from the patient stories shared in the book. How you may develop similar questions.5. A family member’s perspective on consequences and using patient experience to advocate for Safety Across the Board - Lisa Morrise

Case Studies in Patient Safety

The Patient Story

• “Meeting people where they are”

• Providers rarely hear the whole story.

• The story as a source for learning.

• Finishing the story - What can be done in response?

The Trial Meant for You

• Where that title comes from.• Kirsten was born after a 38

week gestation.• I had ultrasounds and

biophysical profiles. Too much amniotic fluid, despite being too low in prior pregnancies.

• No sign of breathing, no surfactant in amniotic fluid

• Problematic delivery• Born with Pierre Robin

Sequence – recessed mandible, complete bilateral cleft palate, retro tongue base

• Immediate airway emergency

Rescued – after two hours

• I met Kirsten after two hours in the REGULAR newborn nursery.

• The Resident.

• The Nurse.

• The NICU.

• The Diagnosis.

• The rest of the story in a nutshell.

Sixteen Years Later

• Annual dinner meeting of Parent to Parent program for the NICU at Kirsten’s birth hospital.

• Introductions around the table.

• We know YOU!

Today

• 44 surgeries later, including three jaw advancement efforts.

• Tracheal malacia and stenosis from tracheotomy – requires laser reduction every 1-2 years.

• Studies Social Work at Utah State.

• We advocate for Safety Across the Board in Healthcare.

Deborah Kilday, MSN, RN

Senior Performance Partner

Quality and Safety Division

Premier, Inc.

Case Studies in Patient Studies:

Foundations in Core Competencies

Thursday, August 27, 2015

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I have no actual or potential conflict of interest in relation to

this program/presentation.

Disclosure

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1999 we learned that 98,000 people were dying every year

from preventable errors in hospitals ~ IOM To Err is Human

2013 it is estimated that more than 440,000 people per

year die from preventable harm in hospitals ~ Journal of Patient Safety

Preventable medical errors ranks 3rd highest killer in U.S.

only to heart disease and cancer. ~ The Leapfrog Group 2013

“We are burying a population the size of Miami every year

from medical errors that can be prevented” ~ The Leapfrog Group 2013

Preventable deaths in hospitals

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Approximately 4.1 million women in the U.S. between the ages of 15

and 50 gave birth from May 2013 to May 2014.

In 2013, 18 mothers died in the U.S. for every 100,000 live births,

The U.S. has FALLEN to 64th in the world on maternal mortality.

The U.S. ranks 3rd in the world for C/S, where 30% of women have

surgical deliveries

Adverse events occur in approximately 9% of all deliveries in the US.

at a cost of $17 billion annually

Maternal mortality

Leading causes of maternal death:

1. Obstetric Hemorrhage

2. Hypertension in Pregnancy

3. Venous Thromboembolism

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U.S. ranks 41st in the world for risk of newborn death ~ 24,000 deaths

Due to high infant mortality rates, the U.S. is ranked 31st as the best

place to have a baby

U.S has the highest first-day infant death rate out of all the

industrialized countries in the world deaths

Neonatal mortality

CDC/NCHS, linked birth/infant death data set

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Estimated 50 - 90% of these events preventable

Just the tip of the iceberg

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“Identify specific triggers for responding to changes in the

mother’s vital signs and clinical condition and develop and

use protocols and drills for responding to changes, such as

hemorrhage and pre-eclampsia. Use the drills to train staff

in the protocols, to refine local protocols, and to identify and

fix systems problems that would prevent optimal care.”

Preventing maternal death

JC SE #44 ~ 2010

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Communication = 72%

Organizational Culture = 55%

Staff competency = 47%

Orientation and training process = 40%

Inadequate fetal monitoring = 34%

Unavailable equipment and/or drugs = 30%

Staffing issues = 25%

Physician unavailable or delayed =19%

Preventing infant death

JC SE # 30 ~ 2004

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Culture of safety

The root of most sentinel events involving injury and death

is a flawed delivery system

This has led many systems to develop highly reliable units

and integrate a rooted culture of safety

General safety culture concepts; Strong leadership

Multidisciplinary team interaction

Adherence to principles of evidence based medicine

Standardized policies and procedures for clinical operations

Common terminology

Timely communication

High degree of emergency readiness

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Improving “Readiness, Recognition and Response”

Implementation of RRT’s as an important strategy in the

prevention of deaths is supported by research from:

Institute of Medicine

Agency for Healthcare

Quality and Research

Institute for Health

Improvement

The American Heart

Association

The Joint Commission

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Practice as a Team

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The Effectiveness of Combined Training Modalities on

Neonatal Rapid Response Teams

“The Effectiveness of Combined Training Modalities on Neonatal Rapid Response Teams” Clinical Simulation in Nursing, Volume 9, Issue 7 , July 2013.

Time is Life ~ Speed is Essential

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Research results

Data Analysis

Increased teamwork and safety

climate

Increased knowledge

assessment scores

Increased team performance

Lessons Learned

Availability of self-inflating

versus flow inflating ambu bags

System standardization of

neonatal code carts

Assignment and management

of equipment checklists

Repair or replacement of

broken or missing equipment

Standardized team education

Practice critical events as a

team

Design of Patient- or Family-

Activated RRT

“The Effectiveness of Combined Training Modalities on Neonatal Rapid Response Teams” Clinical Simulation in Nursing, Volume 9, Issue 7 , July 2013.

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Timed data

Mean Initiation Time AAP NRP Algorithm Time

BVM ventilation

1:12

Chest compressions

1:56

UVC placement

8:56

Epinephrine ETT

7:55

Volume

10:34

BVM ventilation

30 sec to 1 min

Chest compressions

1 min to 1 min 30 sec

UVC placement

< 5 min

Epinephrine ETT

1:30 to 2:00

Volume

< 6 min

Time is Life ~ Speed is Essential

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Readiness: Resources, supplies & equipment

Availability of BloodEmergency Cart

Activated TeamLaryngeal Mask

Pulse Oximeter

Medications

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Common themes of opportunity

2

6

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Recognition: Informed Patients and Families

Awareness of risks, signs and symptoms

How to ask for and call for help

Implement patient education strategies

Target to the educational level of the patients

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You are the most important member of your healthcare

team

Understand what it means to get quality healthcare, and

how to find it

Choose a healthcare team that will partner with you

Learn about your condition and how to care for yourself

Take action if you are not getting the right care

Activated patient and family

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Informed consumer

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Ask questions;

How does your quality of care measure up?

What do your patients say about you?

What are barriers to care (rural communities)?

Are your doctors and nurses board-certified?

What is the organizations compliance with

accreditation for quality and safety standards?

What is your healthcare team's experience in

diagnosing and treating your type of condition?

How do you prepare for and respond to emergencies?

Is 24/7 in-house provider coverage available?

Informed consumer

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Prepare for appointments and procedures

• List your visit goals with the most important ones first

• Bring a friend or family member to appointments

• Bring a list of all your medications

• Share preferences, needs, medical history and other

information

• Actively listen to what the medical team tells you

• Ask more questions

Prepare

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Consumers Advancing Patient Safety - http://www.patientsafety.org/

Hospital Safety Score - http://www.hospitalsafetyscore.org/

Patient Safety America - http://patientsafetyamerica.com/

The Joint Commission - http://www.jointcommission.org/topics/speakup_brochures.aspx

Nursing Home Compare - www.medicare.gov/NHCompare

Hospital Compare - www.hospitalcompare.hhs.gov

Physician Compare - www.medicare.gov/find-a-doctor/provider-search.aspx

Home Health Compare - www.medicare.gov/homehealthcompare

Leapfrog Group - www.leapfroggroup.org

Informed Patient Institute - www.informedpatientinstitute.org

Aligning Forces for Quality - www.forces4quality.org

Partnership for Patients - http://partnershipforpatients.cms.gov/

Solutions for Patient Safety - www.solutionsforpatientsafety.org

Transforming Maternity Care - http://transform.childbirthconnection.org/resource

Council for Patient Safety - www.safehealthcareforeverywoman.org

Safe Motherhood Initiative - Maternal safety materials http://www.acog.org

Preeclampsia Foundation - www.preeclampsia.org

Premier Safety Institute - http://www.premiersafetyinstitute.org/

Premier Advisor Live Education - https://www.premierinc.com/events/

Finding quality national resources

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Our ultimate goal

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Questions and contact information

Deb Kilday, MSN, RN

Senior Performance Partner

Premier Inc.

Deborah_Kilday@premierinc.com

Discussion

• Questions from Case Studies in Patient Safety:

– “What cognitive biases do you think might have contributed to the errors in Kirsten’s care?”

– “Should a family be told if their loved one’s events are being used for teaching? What practical and emotional effects do you think this lack of disclosure might have had on the family?”

– “Do you think disclosure of adverse events is effectively done now?”

More Discussion

• Your questions

• How do you use patient stories in illustrating Safety Across the Board concepts?

• How do you use YOUR story to advocate?

Upcoming Events

• September 24 – Linda Kenney – Supporting Patients and Providers After an Adverse Event

• October 22 – Ilene Corina – Turning Personal Tragedy into Advocacy – Meeting the Needs of Vulnerable Populations