The publication of the Institute of Medicine’s report clearly delineates how knowledge-driven care, coupled with technology, clinical information systems, and various applications, leads to improved outcomes for patients. So many of our hospitals and health systems and various care settings have been moving rapidly to adopt different technologies with the goal of improving outcomes for patients.
For example:
Barcoding and EMAR at the bedside are thought to be the best intervention to prevent those dispensing and administration errors. With barcoding and eMAR orders flow electronically from CPOE to an electronic medication administration record or an eMAR. This eliminates transcription entirely, and nurses have laptops with eMAR, and they use this to track what medications needs to be given or administered. Nurses use barcode scanning of the medication and the patient to verify that the drug they are administering matches the physician’s orders. Right drug, right patient, right dose , and right time can all be checked with the barcode scanning, and the eMAR alerts if any of these are incorrect.
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Electronic health records (EHRs) have been widely adopted over the past decade in both inpatient and outpatient settings. EHR systems are made up of the electronic patient "chart" and typically include functionality for computerized provider order entry (CPOE), laboratory and imaging reporting, and medical device interfaces. Ideally, the system creates a seamless, legible, comprehensive, and enduring record of a patient's medical history and treatment. However, the transition to this new way of recording and communicating medical information has also introduced new opportunities for error and other unanticipated consequences that can present safety risks.
Computerized Provider Order Entry
Is The digital transformation of medicine is by computerized provider order entry (CPOE), which refers to any system in which clinicians directly place orders electronically, with the orders transmitted directly to the recipient. As recently as 10 years ago, most clinician orders were handwritten. Spurred by the 2009 federal HITECH Act and the accompanying Meaningful Use program, CPOE usage rapidly increased in inpatient and outpatient settings. The vast majority of hospitals and most outpatient practices now use some form of CPOE. CPOE systems were originally developed to improve the safety of medication orders, but modern systems now allow electronic ordering of tests, procedures, and consultations as well. The widespread implementation of CPOE has benefited clinicians and patients, but it also vividly illustrates the risks and unintended consequences of digitizing a fundamental health care process.
The process of prescribing and administering a medication involves several steps, each of which has vulnerabilities that are addressed—to greater or lesser degrees—by CPOE:
Ordering: the clinician must select the appropriate medication and the dose and frequency at which it is to be administered.
Transcribing: if handwritten, the prescription must be read and understood by the recipient (usually a pharmacy technician or pharmacist).
Dispensing: the pharmacist must check for drug–drug interactions and allergies, then release the appropriate quantity of the medication in the correct form.
Administration: the medication must be received by the correct person and supplied to the correct patient at the right time in the right dosage. In hospitalized patients,
nurses are generally responsible for this step, but in the outpatient setting, this step is the patient's or caregiver's responsibility.
CPOE systems are generally paired with some form of clinical decision support system (CDSS), which can help prevent errors at the medication ordering and dispensing stages and can improve safety of other types of orders as well. A typical CDSS suggests default values for drug doses, routes of administration, and frequency and may offer more sophisticated drug safety features, such as checking for drug allergies or drug–drug or even drug– laboratory (e.g., warning a clinician before ordering a nephrotoxic medication in a patient with elevated creatinine) interactions.
.We know that the cost of good health care has become excessive, but the cost of poor quality is more than this.
So this video enable you to: Describe the role of Safety Culture as a component of safe and effective care. Explain the concept of Just Culture and its impact on organizational culture, where does Just Culture fit with a Safety Culture. And identify and apply techniques for implementing a culture of safety, so not only taking the concepts but talking about how might you put those into action, especially when you’re attempting to influence just about everybody in the organization, first starting with those colleagues who might be most receptive to learning and to change, and engaging them in that wider and wider circle of helping you to shape the organization and how it functions.
Firstly We do have to change our mentality as leaders. We have to go from one of scarcity -- you’re not getting us enough -- to one of we really have all the resources we need, we need to just use them more wisely. We need to provide hope.
Also , you should have a better sense of what is the patients’ experience and understanding of medical error, at least on the basis of some of the research studies we’ve completed to date, and, secondly, I’d like you to have a sense for what role patients and their families might play in identifying medical error, and, more importantly, in preventing harm. On a conceptual level, there are several conditions that patients or families need to be present in order to prevent medical errors. First of all, they need to be able to identify the errors. Secondly, they have to be able to communicate their concerns to someone, and, finally, they need to behave in a safe way.
As articulated in the seminal Institute of Medicine report Crossing the Quality Chasm, such patient-centered care should be "respectful of and responsive to individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions."
While many patient safety interventions have used traditional models of effecting change, such as changing provider behavior, encouraging collaboration, and enhancing the culture of safety, the patient's role in safety has not been overlooked.
The Joint Commission mandated that health care organizations "encourage patients' active involvement in their own care as a patient safety strategy" as a National Patient Safety Goal in 2007, catalyzing research into how patients may partner with providers to prevent errors–and how patients may themselves inadvertently precipitate errors.
Patients' Role in Preventing Errors
Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.
I show the Joint Commission here in 2004. Of course, the Joint Commission’s been around for a very long time, but around 2004/2005, it did two things that were very important. One is it began its – to promulgate national safety goals – very important safety directives from the Joint Commission that helped to focus the field on certain new practices like the timeout, and universal precautions, and signing your site, and getting rid of high risk abbreviations. Second thing the Joint Commission did – again, in part because of pressure from the safety field – was transform the way it did hospital inspections. Prior to about this time, my hospital had about two or three years notice of the day the Joint Commission was coming to visit. Beginning about 2005, the Joint Commission changed to unannounced surveys in your hospital and mine. Now there’s about 30 minutes notice before the Joint Commission comes to visit.
In summary, the Joint Commission Sentinel Event Alert
And focus on teamwork and communication. According to the Sentinel Event Statistics from October 2007 from the Joint Commission, failed communication has been identified as the root cause of nearly 70 percent of sentinel events.
Sentinel events are defined as "an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof." The NQF's Never Events are also considered sentinel events by the Joint Commission. The Joint Commission mandates performance of a root cause analysis after a sentinel event.
The dynamic environment in which health care is delivered requires clinicians to maintain situational awareness. The concept of situational awareness refers to the ability to access and track data relevant to the task at hand, comprehend the data, forecast what may happen based on the data, and formulate an appropriate plan in response. In a clinical context, maintaining situational awareness requires information sharing and open dialogue among clinicians in order to achieve a shared mental model—the "big picture" of the patient's condition and immediate priorities for care.
The Joint Commission includes "improving staff communication" as one of its National Patient Safety Goals, emphasizing the importance of communicating test results accurately. The National Quality Forum also includes multiple approaches to enhancing communication as part of the Safe Practices for Better Healthcare.
The factors that impair effective communication between providers often relate to cultural norms and expectations within the health care environment. Rigid hierarchies, in which authority gradients discourage frontline workers from raising concerns with leadership, are persistent within health care and a known contributor to preventable harm. Overtly disruptive and unprofessional behavior is less common, but has a chilling effect on communication and teamwork. More subtle issues, such as nonverbal cues, interpersonal relations, and group dynamics, can affect communication in ways that may not be readily apparent, even to the parties involved. In many ways, these factors contribute to the overall culture of safety within an organization.
Approaches to improving communication between clinicians share common goals, but differ depending on the context. Efforts to enhance communication in the course of routine patient care have focused on developing standardized communication protocols for transmission of important information. For example, read-back protocols are now standard practice for communication of critical test results in order to reduce errors of omission. The SituationBackground-Assessment-Recommendation (SBAR) approach is widely used to facilitate communication between nurses and physicians by offering a standardized way of communicating the clinical assessment of a patient requiring acute attention. Used correctly, SBAR can be an effective tool to minimize authority gradients.
At the health care system level, formal teamwork training programs explicitly focus on enhancing communication behaviors within teams, and a growing body of literature
demonstrates that improved team behaviors lead to better patient outcomes. The unit-based safety team model, which emphasizes teamwork training approaches within a geographic unit, has also been effective in improving safety culture. Organizations are also taking a more proactive stance in addressing disruptive and unprofessional behavior by clinicians at all levels.
systems thinking, error theory, and reliable design.
You will be introduced to James Reason’s Swiss Cheese Model of organizational accidents, which has been recognized as the defining model for describing accident causation, and will learn strategies for applying this model to identify the underlying causes of medical errors. With a focus on reliability and the principles of reliable design, .
In order to have a high-reliability organization -- High reliability organizations use systems thinking to evaluate and design for safety, that is, an organization ,that has relatively few accidents versus the risk that it’s exposed to -- the culture has to be a safe one. A safe culture has many attributes, among them being that the people are mindful about what they do, that they are constantly wary about what can go wrong, and prepare to do the right things when something does go wrong. Simulation of various kinds is perhaps one of the best ways to create and sustain such a culture.
This commitment establishes a "culture of safety" that encompasses these key features:
Acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
Organizational commitment of resources to address safety concerns
Organization must have a supportive environment for event reporting that protects the privacy of staff who report occurrences.
Detection of Safety Hazards
You should hopefully be able to explain prospective and retrospective techniques for analyzing system failures and vulnerabilities. I can tell you that in the work I’ve done with organizations, what I believe to be true is that the actual technique is sometimes less important than just the heartfelt effort and the diligence that some staff put into truly understanding every aspect of error. And so using a particular approach may not be as important as really working towards an outcome and then also committing to fixing what you find to be weaknesses. But we’ll talk about the most common prospective and retrospective techniques. And then finally, you should be able to interpret and apply best practices for analyzing data and driving patient safety improvements.
One approach to RCAs –I’ve heard this called questioning to the void – means to repeatedly ask, “How is it so, that something has happened?” Don’t simply ask why it happened, but rather, “How is it that that was able to happen?” If you keep asking that question over and over again, you’ll actually find that you’re revealing additional layers of the problem. And that is really going to yield the kind of analysis that will ultimately solve that problem. The purpose of the Root Cause Analysis needs to be to move the organization away from blaming or focusing on the error operator and being much more consistently focused on the systems that set that person up to fail.
(FMEA) is a common approach to prospectively determine error risk within a particular process. FMEA begins by identifying all the steps that must be taken for a given process to occur ("process mapping") The other process I’m going to talk about briefly is the Failure Mode and Effects Analysis,
sometimes called the Failure Mode and Effects Criticality Analysis. The real benefit of this process, in my mind, is that it is proactive. It seeks to try to identify certain failure modes or certain process issues that could set up a provider to fail or could be, if you will, an accident waiting to happen. When a process or a product or a service, a new service, is being contemplated or designed, that’s really when a Failure Mode and Effects Analysis should be deployed.
Finally
Measuring and Achieving a Culture of Safety
Safety culture is generally measured by surveys of providers at all levels. Available validated surveys include AHRQ's Patient Safety Culture Surveys and the Safety Attitudes Questionnaire. These surveys ask providers to rate the safety culture in their unit and in the organization as a whole, specifically with regard to the key features listed above. Versions of the AHRQ Patient Safety Culture survey are available for hospitals and nursing homes, and AHRQ provides yearly updated benchmarking data from the hospital survey.
Safety culture has been defined and can be measured, and poor perceived safety culture has been linked to increased error rates. However, achieving sustained improvements in safety culture can be difficult. Specific measures, such as teamwork training, executive walk rounds, and establishing unit-based safety teams, have been associated with improvements in safety culture measurements and have been linked to lower error rates in some studies. Other methods, such as rapid response teams and structured communication methods such as SBAR, are being widely implemented to help address cultural issues such as rigid hierarchies and communication problems, but their effect on overall safety culture and error rates remains unproven.
The culture of individual blame still dominant and traditional in health care undoubtedly impairs the advancement of a safety culture. One issue is that, while "no blame" is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of just culture is now widely used. A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (eg, slips), at-risk behavior (eg, taking shortcuts), and reckless behavior (eg, ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event. For example, reckless behavior such as refusing to perform a "time-out" prior to surgery would merit punitive action, even if patients were not harmed.
Measuring and Achieving quality:
In the 1960s, health services researcher Avedis Donabedian defined a taxonomy for measuring the quality of health care. The "Donabedian triad," which is still widely used today, defines three lenses through which quality may be viewed:
Structures—how care is organized
Processes—what is done to the patient
Outcomes—what ultimately happens to the patient
I wish you all the best in your pursuit and with the rest of the courses. Thank you so much