Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer Patient Safety Past, Present, Future

Breakfast With the ChiefsFebruary 1, 2007

Philip HassenChief Executive Officer

Patient Safety

Past, Present, Future

2

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

3

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

Mission

VisionWe 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.

4

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

5

‘‘Will we put the methods of science to work in Will we put the methods of science to work in the evaluation of our practices, or must we the evaluation of our practices, or must we

admit that no matter how much we read, study, admit that no matter how much we read, study, practice and take pains, when it comes to a practice and take pains, when it comes to a

show-down of the results of our treatment, no show-down of the results of our treatment, no one could tell the difference between what we one could tell the difference between what we have accomplished and results of some genial have accomplished and results of some genial

charlatan…?”charlatan…?”

Codman, 1915Codman, 1915

Evolution of Patient Safety

6

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

8

9

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.

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19911991 Harvard Medical Practice StudyHarvard Medical Practice Study19951995 Quality in Australian Health Care StudyQuality in Australian Health Care Study19961996 Annenberg conferences beginAnnenberg conferences begin1999 1999 Colorado / Utah StudyColorado / Utah Study19991999 IOM Report:IOM Report: To Err is HumanTo Err is Human20002000 BMA/BMJ London Conference on Medical ErrorBMA/BMJ London Conference on Medical Error20002000 SAEM: San Francisco Conference on EM ErrorSAEM: San Francisco Conference on EM Error20012001 British studyBritish study____________________________________________________________________________________________

2001-3 Halifax Symposia on Medical Error 2001-3 Halifax Symposia on Medical Error 2001 RCPSC National Steering Committee on Patient 2001 RCPSC National Steering Committee on Patient

SafetySafety2002 RCPSC Report:2002 RCPSC Report: Building a Safer SystemBuilding a Safer System20042004 Canadian Canadian Patient SafetyPatient Safety Institute Institute 2006 62006 6thth Canadian Symposium on Patient Safety Canadian Symposium on Patient Safety

(Vancouver) (Vancouver)

Milestones of the Modern Era

11

Medical Error CitationsMedical Error Citations collated by the National Patient Safety Foundation

for the period 1939-98.

0

20

40

60

80

100

120

Year

Cita

tion

s

12

Adverse Events

• Delayed or missed diagnosesDelayed or missed diagnoses• Medication errorsMedication errors• Wrong side surgeryWrong side surgery• Wrong patient surgeryWrong patient surgery• Equipment failureEquipment failure• Patient identityPatient identity• Transfusion errorsTransfusion errors• Mislabeled specimenMislabeled specimen• Patient fallsPatient falls• Time delay errorsTime delay errors• Laboratory errors Laboratory errors • Radiology errorsRadiology errors• Procedural errorProcedural error

• Lost, delayed, or failures to follow Lost, delayed, or failures to follow up reportsup reports

• Retention of foreign object Retention of foreign object following surgeryfollowing surgery

• Contamination of drugs, Contamination of drugs, equipmentequipment

• Intravascular air embolismIntravascular air embolism• Failure to treat neonatal Failure to treat neonatal

hyperbilirubinemiahyperbilirubinemia• Stage lll or lV pressure ulcers Stage lll or lV pressure ulcers

acquired after admissionacquired after admission• Wrong gas deliveryWrong gas delivery• Deaths associated with restraints Deaths associated with restraints

or bedrailsor bedrails• Sexual or physical assaultSexual or physical assault

13

Why Do Adverse Events Happen?

• In any system or organization that involves In any system or organization that involves humans, error is inevitable because there is humans, error is inevitable because there is a wide variation in performance both within a wide variation in performance both within and between peopleand between people

• Evidence is accumulating that some human Evidence is accumulating that some human dispositions towards error are hard-wireddispositions towards error are hard-wired

• Only a small proportion of error is Only a small proportion of error is egregiousegregious

• Ambient conditions and systemic design Ambient conditions and systemic design increase the likelihood of errorincrease the likelihood of error

• Error has been described as the ‘essential Error has been described as the ‘essential friction’ within all systemsfriction’ within all systems

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Sources of System Error

• Overall cultureOverall culture• Education/Training/ExperienceEducation/Training/Experience• System design / HFESystem design / HFE• Resource availabilityResource availability• Demand/VolumeDemand/Volume• Throughput ImpedanceThroughput Impedance• Shift-work/schedulesShift-work/schedules

Adverse Events

15

A Culture of Safety31,033 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 MedicalIs there a negative impact of fatigue on your performance?

74% 30%

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%

16

1,000,000

100,000

10,000

1000

100

10

1

DEFECTS 50% 31% 7% 1% 0.02% 0.0003%SIGMA 1 2 3 4 5 6

PPM

• Low Back TX

•

Post HeartAttack

Medications

•Mammography Screening

• Tax Advice(phone-in) (140,000 PPM)

•

Medication Accuracy in General

• Airline Baggage Handling

•

Domestic Airline Flight Fatality Rate (0.43 PPM)

Sigma Scale of Measure

Difficulty with Referral

•

Comparative Reliability Between Industries

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

18

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 FactorsFatigue

• 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

21

22

Association Between Evening Admissions and Higher Mortality Rates in the Pediatric Intensive Care Unit

Yeseli Arias, Doublas S. Taylor, and James P. MarcinPediatrics 2004; 113: 530-534

0.4

4.1

0.9

3.9

1.2

1.8

0.9

1.9

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Sepsis CardiacDisease

CardiacArrest

Time ofBirth*

Day

Night

23

Human FactorsMultitasking, 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


24

Human FactorsInherent 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


• 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

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

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Systems Approach to Patient Safety

Measurement and Evaluation

Legal/Regulatory

Education and Professional Development

Information and Communication

System Changes to

Create a Culture of

Safety

EHR

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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

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Reason’s Swiss Cheese Model

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CPSI Strategies and Activities

• Adverse Event Reporting and Learning System

• Root Cause Analysis

• National Disclosure Guidelines

• Safer Healthcare Now!

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Development of a Canadian Adverse Events Reporting and Learning System (CAERLS)

A major initiative in the 2006/07 CPSI Action Plan is to explore thedevelopment of a Canadian Adverse Event Reporting & Learning

System toenable a patient safety knowledge base, create a repository and

facilitateknowledge 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.

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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 teams2. Improved care for acute myocardial infarction3. Prevention of adverse drug effects4. Prevention of central line-associated

bloodstream infection5. Prevention of surgical site infection6. 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

Partner Network

Peer SupportNetwork

CAPHC

Measurement Working Group & CMT Education & Resource

Working Group

Clinical Support

Canadian ICU Collaborative

ISMPCanada

Operations

Teams

Other Canadian Faculty

Communication Working Group

Atlantic

NodeOntario

Node

Western Node

Campaign SupportSHN National Steering Committee

Secretariat - CPSI

Patients

CCHSA CIHI

Quebec

Node

IHI

36

West

Ontario

Atlantic

Quebec

Total

Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)]

45 98 23 10 176

*As of January, 2007

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Teams Continue to Enroll

Saferhealthcare Overview Total # Enrolled Teams September 2005 to January 2007

118

296

403

443

491

541579

0

100

200

300

400

500

600

Total # of Teams EnrolledTeams

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

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Ventilator Associated Pneumonia (VAP)Calgary Health Region

RGH - VAP Incidence by confirmed date

0

10

20

30

40

50

May-04

Jun-04 Jul-04 Aug-04

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

Month

VA

P r

ate

(VA

P c

ases

/100

0 ve

nt

day

s)

x Chart

UCL = 46.11

Mean = 10.30

LCL = 0

Goal 8.4

39

Ventilator Associated Pneumonia (VAP)St. Paul’s Hospital (SK)

Days between VAP cases

050

100150200250300350400

Mar

-5-9

9

May

-31-

99

Jul-3

-99

Nov

-1-9

9

Dec

-20-

99

Mar

-31-

00

June

-15

-00

Sep

-12-

00

Jun-

14-0

1

Mar

-16-

02

Sep

-9-0

3

Aug

-8-0

4

May

-11-

05

Sep

- 30

-05

Nov

-30-

05

Month

Nu

mb

er o

f D

ays

bet

wee

n

case

s

No new cases reported to date

SPH Monthly VAP reports

0

2

4

6

8

10

Apr

-02

Aug

-

Dec

-

Apr

-03

Aug

-

Dec

-

Apr

-04

Aug

-

Dec

-

Apr

-05

Aug

-

Dec

Month

VA

P r

ate

per

100

0 ve

nt.

d

ays

VAP/1000

VAP rate per 1000

02468

101214

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

2004-2005

VAP rate per1000

Jan-Nov

229 days since last reported VAP

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Preventing Central Line Infections

COLLABORATIVE'S CUMULATIVE CRBSI RATES/1000 LINE DAYS6 Pediatric ICU's

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

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

Ra

te p

er

10

00

lin

e d

ay

s . Pediatric Teams Join

Canadian ICU Collaborative

National Nosocomial Infections Surveillance System (NNIS) Rate

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

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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


44

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


45

CPSI Strategies and ActivitiesProfessional 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

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Simulation in CanadaGoal: To facilitate the development of a national

simulation strategy for healthcareObjectives

• To create a national vehicle for the promotion and endorsement of simulation including an infrastructure for collaboration

• To endorse team – focused simulation educationPhases

Phase 1: Endorse and SupportPhase 2: EducatePhase 3: Evaluate

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CPSI Strategies and ActivitiesNational Hand Hygiene CampaignThe 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

48


Patient Safety Competencies ProjectObjectives: • 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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Executive Patient Safety SeriesObjectives:

• 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.

50

CPSI Strategies and ActivitiesCanadian 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

52

Is It Getting Better?

Patient Safety

53

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

55

Much has Been Done …Trend in Age-Adjusted 30-Day In-Hospital

Death Rate

Excludes NL, QC, BC

56

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

Extra hospital days associated with adverse events

Deaths among patients with preventable adverse events

57

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

> 3,200 more livessaved betweenApr 04-Dec 05 vs. 03/04

58

But Variations PersistDistribution of HSMR for facilities with at least 2000 discharges, FY

2004/05 – Adapted international method

0

5

10

15

20

25

30

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

HSMR

Num

ber

of F

acili

ties

59

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.

Human Error – the New View

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

60

HUMAN ERRORS ARE SYMPTOMS OF DEEPER TROUBLE

Human Error – the New View

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

61

62

63

Conclusion

• 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

Safe and Reliable Organizations

64

• 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

Conclusion

Safe and Reliable Organizations

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Seven Steps to Patient Safety1. Lead and support your staff2. Foster a culture of safety3. Promote reporting4. Involve patients and the public5. Implement solutions to reduce / avoid harm6. Learn and share safety solutions7. 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”

Conclusion

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“Culture eats strategy for lunch over & over again”

Marc Bard

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

Documents

Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer Patient Safety Past, Present, Future