AHRQ Safety Program for Surgery Implementation AHRQ Pub No 1618000415EF December 2017 Learning Objectives Describe difference between firstorder and secondorder problem solving List contributing factors that make defects in care more likely to occur ID: 706164
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Learning From Defects Through Sensemaking
AHRQ Safety Program for SurgeryImplementation
AHRQ Pub. No. 16(18)-0004-15-EF
December 2017Slide2
Learning ObjectivesDescribe difference between first-order and second-order problem solvingList contributing factors that make defects in care more likely to occur
Use the Learning From Defects (LFD) tool to perform second-order problem solvingLearning From Defects 2Slide3
Principles of Safe DesignPatient safety is a property of systems
Apply principles to both technical tasks and adaptive teamworkTeams make wise decisions when input is diverse, independent, and encouragedLearning From Defects 3Slide4
Problem-Solving HierarchyFirst-order problem solving
Recovers for one patient, but does not reduce risks for future patientsExample: You get the supply from another area or you manage without itSecond-order problem solvingReduces risks for future patients by improving work processes and increasing complianceExample: You create a process to make sure line cart is stocked with necessary equipmentLearning From Defects 4Slide5
Problem-Solving Goal
What is the long-term impact on patient safety culture?Learning From Defects 5Slide6
What Is a Defect?
Anything
you do not
want to happen
again.
Learning From Defects
6Slide7
Individual Mistake or System Failing?
Rather than being the main instigators of an accident, operators tend to be the inheritors of
SYSTEM
defects. . . . Their part is that of adding the final garnish to a
lethal brew
that has been long in the cooking.
--
James Reason,
Human Error
, 1990
1
“
”
Learning From Defects
7Slide8
Source of DefectsAdverse-event reporting systems
Sentinel eventsClaims dataInfection ratesComplicationsPerioperative Staff Safety AssessmentsHow will the next patient be harmed?What can you do to prevent or minimize this harm?Learning From Defects 8Slide9
Learning From Defects
Learning From Defects 9
3
4
2
1Slide10
Who Should Use the LFD Tool?Core CUSP team guides the process with LFD tool
CUSP FacilitatorCUSP ChampionUnit ManagerProvider ChampionSenior ExecutiveEveryone on the unit can and should participate in the process of learning from defectsLearning From Defects 10Slide11
Check Your AssumptionsCUSP brings a diverse group of team members togetherDon’t
assume everyone is as familiar with the details of defect as you areNot familiar with the context of a defect being discussed? Don’t hesitate to ask basic questions!Well-versed? Take the time to describe the defect so everyone can help you see aspects of the defect you may not have appreciated beforeWalk the process with the frontline staffLearning From Defects 11Slide12
What Happened?Select a defect to explore
Put yourself in the place of those involved, in the middle of the event as it was unfoldingTake time to listenSeek to understand rather than to judgeAsk clarifying and followup questionsDig down to the reasoning and emotions behind actions and decisionsLearning From Defects 12Slide13
What Happened?
Learning From Defects 13Slide14
What Happened?Reconstruct the timeline and explain what happened
Consider recreating to make defect realVisualization toolsProcess mappingRole playingDiagrams or sketchesTo create a lasting change, remember the human factors involved in every defect, including the values, attitudes, and beliefsLearning From Defects 14Slide15
Why Did It Happen?Contributing factors from all levels of your
health care system impact care delivery and, ultimately, patient outcomesDevelop a “system perspective” to see the hidden factors that led to the eventList all contributing factors and identify whether they harmed or protected the patientThis process is instrumental in building second-order problem-solving skills necessary to learn from defectsLearning From Defects 15Slide16
Why Did It Happen?
Patient suffers
1
st
2
nd
3
rd
5
th
4
th
System Failure Cascade
1,2
Learning From Defects
16Slide17
System Factors Impact Safety3
Hospital
Departmental
Factors
Work
Environment
Team
Factors
Individual
Provider
Task Factors
Patient Characteristics
Institutional
17
Learning From Defects
17Slide18
LFD Tool Contributing FactorsLearning From Defects
18Slide19
LFD Tool Contributing FactorsLearning From Defects
19Slide20
LFD Tool Contributing FactorsLearning From Defects
20Slide21
Why Did It Happen?As you identify contributing factors, try to go deeperThe “5 Why’s” technique can help
Why 1: Why did this contributing factor occur?Why 2: Why did the answer to “Why 1” occur?Why 3: Why did the answer to “Why 2” occur?Why 4: Why did the answer to “Why 3” occur?Why 5: Why did the answer to “Why 4” occur?It might take more than one meeting and additional fact-finding to find all contributing factorsLearning From Defects 21Slide22
Why Did It Happen?If your team used a drawing to illustrate what happened, consider revisiting it
Look for weaknesses in the processesAre there redundant steps?Are there variables that make care inconsistent among providers?Evaluate the way your workspaces are designedIs the workflow reasonable?Is the workflow efficient?Learning From Defects 22Slide23
Why Did It Happen?What about the people side of the defect?Can you identify where the pain points are?
Are there aspects of your patient safety culture that promote doing the wrong thing or engaging in a risky workaround?What might your team do to build a stronger safety culture?Learning From Defects 23Slide24
CASE STUDY: RENAL TRANSPLANT
Communicating for Patient Safety24
Learning From Defects
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AHRQ Safety Program for Surgery
Implementation
Slide25
Case Study: Renal TransplantWho:
A patient bleeding after renal transplantWhat: Needs emergency surgery to correctWhen: Early morning 0530Where: Taken to operating room (OR) by anesthesiology teamAnd: Nurse hands over chart with Kardex stamp plate as patient leaves intensive care unit (ICU)What happened next?In OR: Patient unstable on arrival to OR at 0600, necessitating additional linesIn OR: Patient stabilized and surgery beginsSetting the stage
Learning From Defects
25Slide26
Case Study: Renal Transplant
Attending anesthesiologist called to an emergent neurosurgical case for craniotomyAttending leaves renal transplant case, returns at 0730Meanwhile, nursing and OR tech staff turns over at 0700 Anesthesiology resident who started the case has already signed out to the day-shift resident who has taken overAttending notes that a transfusion has started, and that the unit of blood has the wrong patient’s nameAttending immediately stops the transfusion, reporting error to the OR staff and blood bankLearning From Defects 26Slide27
Case Study: Renal TransplantResident used the stamp plate to order and then check the blood
However, the wrong chart was sent with the patient from the ICUChart was never checked against the wrist bandAll of the OR documents stamped with the name from the incorrect chartUltimately, the patient dies, though transfusion not the cause as the donor blood was type OLearning From Defects 27Slide28
Case Study: Renal Transplant
What happened?Why did it happen?How will you reduce the risk of the defect happening again?How will you know the risk is reduced?Learning From Defects 28Slide29
Case Study: Renal Transplant
System Failures
Knowledge, Skills & Competence
Anesthesiology
attending not notified of the
transfusion; wrist
band checks with stamp plate were not done at multiple
points
Unit
Environment
Near
simultaneous emergent
events;
change of two different provider groups at same
time; no
independent
check
Other Factors
Hospital environment
: Transfer across units
Patient characteristics:
High acuity
Task characteristics:
Blood check-in only as good as existing identity documents
Create independent checks, encourage patient safety culture initiatives, add system constraints like barcoding technologies
Stagger staff changes
Formalize handoffs between departments
Ensure handoff process supports emergencies
Opportunities for Improvement
Learning From Defects
29Slide30
Action PlanReview the Learning From Defects tool with your teamReview
the defects in your operating roomsSelect a defectIdentify the top three contributing factorsShare those factors with your staffLearning From Defects 30Slide31
Learning From Defects Through Sensemaking II
AHRQ Safety Program for SurgeryImplementation Slide32
Learning ObjectivesUse the LFD tool to perform second-order
problem-solvingCreate an action plan to address prioritized contributing factorsEvaluate the effectiveness of your intervention by measuring baseline and post-intervention performancePresent your findings to surgical department leadershipLearning From Defects 32Slide33
Learning From Defects
Learning From Defects 33
1
2
3
4Slide34
Case Study: Renal Transplant
System Failures
Knowledge, Skills & Competence
Anesthesiology
attending not notified of the
transfusion; wrist
band checks with stamp plate were not done at multiple
points
Unit
Environment
Near
simultaneous emergent
events;
change of two different provider groups at same
time; no
independent
check
Other Factors
Hospital environment
: Transfer across units
Patient characteristics:
High acuity
Task characteristics:
Blood check-in only as good as existing identity documents
Create independent checks, encourage patient safety culture initiatives, add system constraints like barcoding technologies
Stagger staff changes
Formalize hand-offs between departments
Ensure handoff process supports emergencies
Opportunities for Improvement
Learning From Defects
34Slide35
How Will You Reduce Risk of It Happening Again?
What is its impact on causing the defect?Does it occur rarely or have a high likelihood of reoccurring?Learning From Defects 35Slide36
Involve the entire team with flipcharts and sticky notes
Prioritize most important contributing factors and most beneficial interventionsTake advantage of your diverse team!Senior executive’s big-picture view of the organization and knowledge of resourcesTeam members’ connections throughout organizationFrontline staff with particular insight into the defectLearning From Defects 36How Will You Reduce Risk of It Happening Again?Slide37
Make choices and select your interventionHave your team vote on its favorite solutions
Consider rating solutions based on direct and feasible way to address the defectLearning From Defects 37WeakerTelling someone to be more carefulIntermediateEliminating or reducing distractions
Stronger
Making a
process or device
“mistake proof”
How Will You Reduce Risk of It Happening Again?Slide38
Building Resiliency Into InterventionsLearning From Defects 38
StrongestSTRENGTH OFINTERVENTIONWeakest
38Slide39
Not All Education Is Created EqualAvoid information overload in all manners of disseminating information
Share a concise message with a clear focus relevant to specific audience needsExperiential learning with hands-on approach will be far more effective at motivating change than an automated email dense with dataLearning From Defects 39Slide40
Remember the people side of the interventionConsider who influences and impacts your interventionAre they likely to support or resist your intervention?Create an action plan to get them on
boardLearning From Defects 40STAKEHOLDERACTION PLAN TO ENGAGELEAD POINT ON ACTION PLANFOLLOW-UP DATE FOR LEAD REPORT
How Will You Reduce Risk of It Happening Again?Slide41
How Will You Reduce Risk of It Happening Again?
Engagement is hard!Use the wisdom of your diverse team to overcome barriers and solve problemsMake sure the intervention details are spelled out and understood by everyoneEnsure the intervention is carried out consistentlyLearning From Defects 41Slide42
Do staff know about the interventions?Are staff using the interventions as intended?Do staff believe risks were reduced?Subjective evaluations can provide valuable information
Data-driven metrics should be the goal whenever possibleLearning From Defects 42How Will You Reduce Risk of It Happening Again?Slide43
How Will You Know Risks Were Reduced?Identify how you will measure success
Put an audit plan in place to track that measureInclude a way to feed data back to your groupReview your audits and adjust your intervention as neededRevisit Learning From Defects process as neededLearning From Defects 43Tip: Learning From Defects is a continuous process,
as is the need to engage frontline staff.Slide44
How Will You Know Risks Were Reduced?Evaluate the effectiveness of your intervention by measuring baseline and post-intervention performancePresent your findings to surgical department leadership
Learning From Defects 44Slide45
How Will You Know Risks Were Reduced?Learning From Defects 45
PLANMEASURE OF SUCCESSWHO MEASURES AND HOW OFTENWHERE RECORDEDFOLLOWUP DATECORRECTIVE ACTIONSlide46
Ongoing Key QuestionsLearning From Defects 46
46
Tip:
Remember that the Learning
From
Defects tool addresses both technical tasks and adaptive teamwork issues.Slide47
Action PlanReview the Learning From Defects tool with your teamReview
one defect in your operating roomsSelect a defect each month or quarterConsider using in surgical morbidity and mortality conferencesPost the stories of reduced risks (with data!)Share with othersLearning From Defects 47Slide48
ReferencesReason J. Human Error. Cambridge, England: Cambridge University Press, 2000
.Pronovost PJ, Wu Aw, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140(12):1025-33. PMID: 15197020.Vincent C, Taylor-Adams S, Stanhope N. Framework for Analyzing Risk and Safety in Clinical Medicine. BMJ. 1998;316:1154-7. PMID: 9552960.Learning From Defects 48Slide49
Additional ReferencesBagian JP,
Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv. 2001;27:522-32. PMID: 11593886.Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102-108. PMID: 16568924.Wu AW, Lipshutz AK, Pronovost PJ. The effectiveness and efficiency of root cause analysis. JAMA. 2008;299:685-87
. PMID: 18270357.
Learning From Defects
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