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Patient Safety

Past, Present, Future

Breakfast With the Chiefs


February 1, 2007
Philip Hassen
Chief Executive Officer
Presentation Overview

• Introduction to Patient Safety and CPSI


• Nature of the Problem
• Evolution of Patient Safety
• Systems Approach vs.
Medical/Community Approach
• Current Activities and Goals
• Conclusion

2
Mission
To provide national leadership in building and
advancing a safer Canadian health system

Vision
We envision a Canadian health system where:
• Patients, providers, governments and others work together to build and
advance a safer health system;

• Providers take pride in their ability to deliver the safest and highest quality
of care possible; and

• Every Canadian in need of healthcare can be confident that the care they
receive is the safest in the world.
3
Definitions

Patient Safety:
The reduction and mitigation of unsafe acts within the health-
care system, as well as through the use of best practices
shown to lead to optimal patient outcomes.
Canadian Patient Safety Dictionary, 2003

Adverse Event:
An adverse event is an unintended injury or complication
which results in disability, death or prolonged hospital stay,
and is caused by health-care management.
Wilson et al

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Evolution of Patient Safety

‘Will we put the methods of science to work in the


evaluation of our practices, or must we admit that no
matter how much we read, study, practice and take
pains, when it comes to a show-down of the results of
our treatment, no one could tell the difference between
what we have accomplished and results of some genial
charlatan…?”

Codman, 1915

5
What Patient Safety Is and Is Not

• It is not what most of us were thinking about 10


years ago
• It is not what ‘we have always done’
• It is the most significant change in the
healthcare system in over a century
• It is a new applied science
• It has forever changed the face of modern
healthcare

6
8
What We Know
Canadian Institute for Health Information
(2004)

• One in nine adults contract infection in hospital.

• One in nine patients receive wrong medication or


wrong dose.

• More deaths after experiencing adverse events in


hospital than deaths from breast cancer, motor
vehicle and HIV combined.
9
Milestones of the Modern Era
1991 Harvard Medical Practice Study
1995 Quality in Australian Health Care Study
1996 Annenberg conferences begin
1999 Colorado / Utah Study
1999 IOM Report: To Err is Human
2000 BMA/BMJ London Conference on Medical Error
2000 SAEM: San Francisco Conference on EM Error
2001 British study
______________________________________________

2001-3 Halifax Symposia on Medical Error


2001 RCPSC National Steering Committee on Patient Safety
2002 RCPSC Report: Building a Safer System
2004 Canadian Patient Safety Institute
2006 6th Canadian Symposium on Patient Safety (Vancouver)

10
Medical Error Citations
Medical Error Citations collated by the National Patient Safety Foundation
for the period 1939-98.

120
100
Citations

80
60
40
20
0
39

51
59

63

66

69

72

75

78

81

84
87

90

93

96
Year

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Adverse Events
• Delayed or missed diagnoses • Lost, delayed, or failures to follow up
• Medication errors reports
• Wrong side surgery • Retention of foreign object following
• Wrong patient surgery surgery
• Equipment failure • Contamination of drugs, equipment
• Patient identity • Intravascular air embolism
• Transfusion errors • Failure to treat neonatal
hyperbilirubinemia
• Mislabeled specimen
• Stage lll or lV pressure ulcers acquired
• Patient falls after admission
• Time delay errors • Wrong gas delivery
• Laboratory errors • Deaths associated with restraints or
• Radiology errors bedrails
• Procedural error • Sexual or physical assault

12
Why Do Adverse Events Happen?

• In any system or organization that involves


humans, error is inevitable because there is a
wide variation in performance both within and
between people
• Evidence is accumulating that some human
dispositions towards error are hard-wired
• Only a small proportion of error is egregious
• Ambient conditions and systemic design
increase the likelihood of error
• Error has been described as the ‘essential
friction’ within all systems
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Sources of System Error
Adverse Events
• Overall culture
• Education/Training/Experience
• System design / HFE
• Resource availability
• Demand/Volume
• Throughput Impedance
• Shift-work/schedules

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A Culture of Safety
31,033 Pilots, Surgeons, Nurses and Residents Surveyed*
*Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross
sectional surveys. BrMedJour, 3-18-2000.

% Positive Responses from: Pilots Medical


Is there a negative impact of fatigue on your 74% 30%
performance?

Do you reject advice from juniors? 3% 45%

Is error analysis system-wide? 100% 30%

Do you think you make mistakes? 100% 30%

Easy to discuss/report mistakes? 100% 56%

15
Comparative Reliability Between
Industries
PPM Difficulty with Referral
1,000,000 Mammography Screening
• ••
100,000
• •• Tax Advice
(phone-in) (140,000 PPM)
10,000 Low
Back TX
Post Heart
Attack Medication • Airline Baggage Handling

1000 Medications Accuracy in


General Domestic
100 Airline Flight
Fatality Rate
10 (0.43 PPM)
1 •
DEFECTS 50% 31% 7% 1% 0.02% 0.0003%
SIGMA 1 2 3 4 5 6
Sigma Scale of Measure
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Source: Institute for Healthcare Improvement
Imagine:
$15 billion in annual purchases hand-written on slips of
paper The Canadian prescription drug industry

1 billion service events scheduled manually over the phone


Annual diagnostic test events in Canada

An industry that does not increase productivity


The healthcare industry in Canada comprises almost 10% of the economy

A service industry that injured 7.5% of its customers through


preventable errors (30% of injuries resulting in permanent
impairment, 5-10% resulting in death)
Hospital care in Canada
THEN WE HAVE HUMAN FACTORS

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Human Factors

“Health care is the only industry that does


not believe that fatigue diminishes
performance.”
Lucian Leape

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Human Factors
Fatigue
• 24 hours without sleep is equivalent to a blood
alcohol level of 0.10 – a 30% decrease in cognitive
processing
• Nurses are 3 times more likely to make mistakes
after 12 hours on the job
• Interns made 30% more errors in ICU patients
when on traditional 24 hour call schedules
• The best countermeasure for fatigue is teamwork
–more people in the movie
• 3 major disasters related to night time workers:
Exxon Valdez, Chernobyl, and Three Mile Island.
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

20
21
Association Between Evening Admissions and Higher
Mortality Rates in the Pediatric Intensive Care Unit
Yeseli Arias, Doublas S. Taylor, and James P. Marcin
Pediatrics 2004; 113: 530-534

4.5
4 4.1
3.9
3.5
3
2.5
Day 2
Night
1.5
1.8 1.9
1 0.9 1.2
0.9
0.5
0.4
0
Sepsis Cardiac Cardiac Time of
Disease Arrest Birth*

22
Human Factors
Multitasking, Interruptions, Distractions

• Humans are poor multi-taskers


• Drivers on cell phones have 50% more
accidents, 25% of traffic accidents are
“distracted drivers”
• Interruptions and distractions increase
error rates
• Humans need very formal cues to get back
on task when interrupted and distracted
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

23
Human Factors
Inherent Human Limitations

• Limited memory capacity – 5-7 pieces of


information in short term memory
• Negative effects of stress – error rates
– Tunnel vision
• Negative influence of fatigue and other
physiological factors
• Limited ability to multitask – cell phones and
driving
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

24
Patient Safety: Barriers to Action

• Difficulty recognizing errors


• Lack of information systems to identify errors
• Relationship of trust with providers
• Access is more urgent in Canada
• Leadership turnover
• Fragmentation of care delivery hampers systems
thinking
Patient Safety: Barriers to Action
• Poor capital investment framework favours short
term needs

• Shortages of clinical professionals

• Concern about liability

• Jurisdictional conflicts

• Simplistic approach to building the EHR

• Culture of patient safety is lacking


Systems Approach to Patient Safety

Measurement and Legal/Regulatory


Evaluation

EHR System
Changes to
Create a
Culture of
Safety

Education and
Professional Information
Development and Communication

27
A Systems Approach

“The systems approach is not about


changing the human condition but
rather the conditions under
which humans work.”

J.T. Reason, 2001

28
Reason’s Swiss Cheese Model

29
CPSI Strategies and Activities
• Adverse Event Reporting and
Learning System

• Root Cause Analysis

• National Disclosure Guidelines

• Safer Healthcare Now!

30
Development of a Canadian Adverse Events
Reporting and Learning System (CAERLS)
A major initiative in the 2006/07 CPSI Action Plan is to explore the
development of a Canadian Adverse Event Reporting & Learning System to
enable a patient safety knowledge base, create a repository and facilitate
knowledge transfer to inspire innovation and safety improvement.

Activity to date includes:


1. The synthesis of findings on adverse event reporting and learning
systems related to:
• international site visits
• an extensive literature search and review
• a comprehensive review of applicable Canadian legislation and policy.

2. Development and circulation of a consultation paper outlining


recommended options for a non-punitive national adverse event
reporting and learning system so that the information can
be sorted, integrated, evaluated and acted upon in a highly
coordinated and timely manner.

31
The Canadian Root Cause
Analysis Framework
What is Root Cause Analysis?
• An analytic tool that can be used to perform a comprehensive,
system-system based review of critical incidents. 1

History
• In January of 2005 CPSI partnered with ISMP Canada and
Saskatchewan Health, to begin work on the development of the
Framework.

Goals of the partnership


• To standardize information and processes related to RCA in Canada.
• To utilize those with known expertise in use of the process and
knowledge transfer of the tool to assist with the development of the
framework.
1 Hoffman,
C., Beard P., Greenall,J., U,D., & White, J. (2006).
Canadian Root Cause Analysis Framework. Edmonton AB: Canadian Patient Safety Institute

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National Guidelines for Disclosure
of Adverse Events
• National Working Group
• Project Charter – full endorsement
• Background Document
• Literature Search and Review
• Final Draft – Feb 2007
• Nationwide Consultation – Mar – April 2007
• Nationwide Endorsement – May – Aug 2007
• Publication and Distribution – October 2007
(Halifax 7)

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Safer Healthcare Now!
Interventions

1. Deploying rapid response teams


2. Improved care for acute myocardial infarction
3. Prevention of adverse drug effects
4. Prevention of central line-associated
bloodstream infection
5. Prevention of surgical site infection
6. Prevention of ventilator associated Pneumonia
Retrieved from www.saferhealthcarenow.ca or
www.soinsplussursmaintenant.ca
Toll free#: 1-866-421-6933

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Campaign Structure
Campaign Support
SHN National Steering Committee
Secretariat - CPSI

CCHSA Clinical Support CIHI

Operations

Teams Quebe IHI


Western c
Node Atlantic
Node Patients Node
Canadian Ontario
ICU Node Other
Collaborative Canadian
Peer Faculty
Support CAPHC ISMP Partner
Network Canada Network

Measurement Communication
Working Group & CMT Working Group
Education & Resource
Working Group
35
West Ontario Atlantic Quebec Total

Healthcare
Delivery
Organizations
[includes hospitals,
agencies, services 45 98 23 10 176
and regions (with
one or more
hospitals
participating)]

*As of January, 2007

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Teams Continue to Enroll
Saferhealthcare Overview Total # Enrolled Teams September 2005 to January 2007

600 579
541
491
500
443
403
400

296
300

200

118
100

0
Total # of Teams EnrolledTeams

Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Oct-06 Jan-07


37
Ventilator Associated Pneumonia (VAP)
Calgary Health Region

RGH - VAP Incidence by confirmed date

x Chart
50
UCL = 46.11

40
VAP rate (VAP cases/1000 vent days)

30

Mean = 10.30

20

10
Goal 8.4

LCL = 0

0
May- Jun-04 Jul-04 Aug- Sep- Oct-04 Nov- Dec- Jan-05 Feb- Mar- Apr-05 May- Jun-05 Jul-05 Aug- Sep-
04 04 04 04 04 05 05 05 05 05
Month

38
Ventilator Associated Pneumonia (VAP)
St. Paul’s Hospital (SK)
Days between VAP cases

Number of Days between


400
350 No new cases
300
reported to date
cases 250
200
150
100
50
0

Nov-1-99

Nov-30-05
Jul-3-99

Jun-14-01
June -15-00
Mar-5-99

Mar-31-00

Mar-16-02
Sep-9-03
Aug-8-04
May-31-99

May-11-05
Dec-20-99

Sep-12-00

Sep- 30-05
229 days since last reported VAP
Month

SPH Monthly VAP reports VAP rate per 1000


VAP rate per 1000 vent.

10 14
8 12
VAP rate per
10
6 1000
days

VAP/1000 8
4 6
2 4 Jan-Nov
0 2
0
Aug-
Dec-

Aug-
Dec-

Aug-
Dec-

Aug-
Apr-02

Apr-03

Apr-04

Apr-05

Dec

1999- 2000- 2001- 2002- 2003- 2004-


Month
2000 2001 2002 2003 2004 2005
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Preventing Central Line Infections
COLLABORATIVE'S CUMULATIVE CRBSI RATES/1000 LINE DAYS
6 Pediatric ICU's

7.0

National Nosocomial Infections Surveillance System (NNIS) Rate


6.0

5.0
Rate per 1000 line days .

Pediatric Teams Join


Canadian ICU Collaborative
4.0

3.0

2.0

1.0

0.0
Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06

40
Rapid Response Team
University of Alberta

# Cardiac ICU
Arrests ALOS
Pre-implementation 7 (4.0 per 100 separations) 10.2
Post-implementation 1 (0.8 per 100 separations) 6.4

Total # calls 24

Source: ICU Collaborative

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CPSI Strategies and Activities

• Research
• Professional Development
• Simulation
• National Hand Hygiene Campaign
• Patient Safety Competencies Project
• Executive Patient Safety Series
• Canadian Patient Safety Officer Course

42
CPSI Strategies and Activities
Research - 2005
– With CIHR, CHSRF and safety leaders safety
research priorities
– Launched 2005 CPSI grants competition
• 327 registered projects
• 125 full applications received
• 57 peer-reviewed
• 28 funded ($1.9M)
– Co-funded with CHSRF two REISS programs
• Pediatric and Adult Acute Care, Family Medicine
– Two Projects Funded with CIHR
43
CPSI Strategies and Activities
Research - 2006/07
– Launched 2006/07 CPSI grants competition
• 64 full applications received
• 35 peer-reviewed
• 15 funded ($1.4M)
– Launched with CIHR a Patient Safety Priority
Announcement
• Grants
• Fellowships
– Partner in the “Listening for Direction” health services
research priority setting initiative with CHSRF, CIHR,
CADTH, CH, CIHI, Health Canada, Statistics Canada
– Partnered with CIHR, CADTH, CIHI, Statistics Canada,
CHSRF to study post marketing surveillance and
effectiveness
44
CPSI Strategies and Activities
Professional Development
- Leading the Safety Process
In partnership with the CMA and the CMPA, CPSI is
developing a workshop in which participants will learn:
– the key best practice approaches to patient safety
– how to build a culture of safety & reporting while
maintaining professional accountability
– how to disclose adverse events to patients
– Participants will also practice the effective
communication skills and techniques when confronted
with critical incidents

45
CPSI Strategies and Activities
Simulation in Canada
Goal: To facilitate the development of a national simulation
strategy for healthcare
Objectives
• To create a national vehicle for the promotion and
endorsement of simulation including an infrastructure
for collaboration
• To endorse team – focused simulation education
Phases
Phase 1: Endorse and Support
Phase 2: Educate
Phase 3: Evaluate

46
CPSI Strategies and Activities
National Hand Hygiene Campaign
The Canadian Patient Safety Institute, the Canadian Council for Health
Services Accreditation, the Public Health Agency of Canada and the
Community and Hospital Infection Control Association are working
together to support, supplement and integrate existing hand hygiene
initiatives locally, regionally and provincially, by developing and
implementing a hand hygiene campaign across Canada.

Campaign Goal:
•To promote the importance of hand hygiene in reducing the
spread of healthcare associated infections in Canada

Campaign Objective:
•To respond to the needs of healthcare organizations for capacity building,
leadership development, and/or the production of tools to help promote
hand hygiene
47
CPSI Strategies and Activities
Patient Safety Competencies Project
Objectives:
• Identify the key knowledge, skills and attitudes
related to patient safety competencies for all
healthcare workers
• Develop a simple, flexible framework that will
act as a benchmark for training, educating and
assessing healthcare professionals in patient
safety
• Help make patient safety competencies easy for
everyone to understand and apply
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CPSI Strategies and Activities
Executive Patient Safety Series
Objectives:
• Describe how you can better fulfill your
responsibilities and accountabilities for patient
safety at the Board/Executive level;
• Understand the methods to effect a cultural shift in
your organization to improve patient safety;
• Create and share safety practices that can be
adapted and established in your organization; and
• Position safety in the context of quality in your
organization.

49
CPSI Strategies and Activities
Canadian Patient Safety Officer Course
With the help of faculty experts, this course will be delivered through
interactive workshops, networking and presentations by patient safety
leaders for healthcare professionals and leaders involved in patient safety
(patient safety officers, clinical managers and physicians)

Overall objectives:
• Provide the skills to create, implement, and maintain a vigorous and
focused patient safety program
• Help develop detailed, customized patient safety strategies and
implementation plans

Dates: September 24-28, 2007

Location: The Kingbridge Centre, Toronto, Ontario


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Other Important Tools
• Resource Crew Management Briefings

• S-B-A-R
– Situation
– Background
– Assessment
– Recommendation

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Patient Safety

Is It Getting Better?

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What is HSMR?
• HSMR track changes in hospital mortality
rates in order to:
– Reduce avoidable deaths in hospitals
– Improve quality of care
• Developed in the UK in mid-1990s by Sir
Brian Jarman of Imperial College
• Used in hospitals worldwide (i.e. UK,
Sweden, Holland and US)

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HSMR is easy to interpret

• Equal to 100
– No difference between facility’s mortality
rate and average rate
• More than 100
– Facility’s mortality rate is higher than the
average rate
• Less than 100
– Facility’s mortality rate is lower than the
average rate
54
Much has Been Done …
Trend in Age-Adjusted 30-Day In-Hospital
Death Rate

Excludes NL, QC, BC

55
What Does Average Mean?
(Results from Baker/Norton)

Deaths among Extra hospital days


patients with associated with
preventable adverse adverse events
events

56
Efforts to Date
(Preliminary based on data as of March 2006)

> 3,200 more lives


saved between
Apr 04-Dec 05
vs. 03/04

57
But Variations Persist
Distribution of HSMR for facilities with at least 2000 discharges, FY
2004/05 – Adapted international method

30

25
Number of Facilities

20

15

10

0
41-60 61-70 71-80 81-90 91-100 101-110 111-120 121-130 131-140 141-150 151-160

HSMR
58
Human Error – the New View

The point of an investigation is not to


find where people went wrong.

It is to understand why their


assessments and actions made sense
at the time.

Sidney Dekker (2002); The Field Guide to Human Error Investigations

59
Human Error – the New View

HUMAN ERRORS ARE


SYMPTOMS OF DEEPER
TROUBLE

Sidney Dekker (2002); The Field Guide to Human Error Investigations

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61
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Conclusion

Safe and Reliable Organizations


• Accept that accidents are inevitable and failure will
occur
• Accept that impact of failure can be minimized
• Promote a safety culture
• Listen to and support front-line workers
• Establish a framework that recognizes costs of failure
and benefits of reliability
• Involve managers in communicating overall picture

63
Conclusion

Safe and Reliable Organizations


• Train managers to recognize and respond to system
abnormalities
• Become adaptive – learn quickly and efficiently from
adverse events
• Make knowledge about problems available
throughout organization
• Design redundancy to create more opportunity to
detect and correct
• Avoid shaming, blaming and organizational hubris
• Don’t micro-manage – allow decision migration
- Croskerry, EPSS Nov 2006

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Conclusion

Seven Steps to Patient Safety


1. Lead and support your staff
2. Foster a culture of safety
3. Promote reporting
4. Involve patients and the public
5. Implement solutions to reduce / avoid harm
6. Learn and share safety solutions
7. Integrate your safety management activity
Adapted from: National Patient Safety Agency for the National Health Service
“Seven Steps to Patient Safety – An Overview Guide for NHS Staff”

65
“Culture eats strategy for lunch
over & over again”
Marc Bard

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High Reliability Organizations are Pre-occupied
with the Possibility of Failure

“…there are some


patients we cannot
help, there are none
we cannot harm...”
Arthur Bloomfield, M.D.
Quality of Healthcare in America Project 2003

-----Dr. Ken Stahl