risk management & patient safety · improve patient care through the strengthening of systems...

Risk Management & Patient Safety

Noelani Warren, PhD., RNDirector for Risk Management & Patient SafetyRiverside Service Area

Regional Advanced Perianesthesia Course

FINANCIAL DISCLOSURE

Disclosure: The faculty and planners for this activity do not have any relevant financial relationships with

commercial interests or affiliations to disclose.

3 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Objectives

To utilize safety check and escalation protocol when applicable

To participate in comprehensive systematic analyses as needed

Questions

To identify potential risks and report them, including near misses

To utilize TeamSTEPPS principles in team communication

WHY: Medical Errors 3rd most common cause of death

4 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

What does Risk Management do?

Improve patient care through the strengthening of systems and processes

Facilitate investigations, identify causes, and potential solutions

Handle legal claims and board reports

Non-punitive, invisible consultants, not to be documented in the record

We represent you, your physicians, AND the patient

We uphold safety science

5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

6 | Copyright © 2017 Kaiser Foundation Health Plan, Inc.

Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year

Not errors but learning opportunities

“ALL MEN MAKE MISTAKES

BUT ONLY WISE MEN LEARN FROM THEIR MISTAKES”

2011-2017 Legal Costs

9

SCAL Significant Events 2014 - 2019

10

Comprehensive Systematic Analysis: Cause Map

11 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

UNFORTUNATELY TECHNOLOGIES AND POLICIES NEED TO

BE IMPLEMENTED BY PEOPLE.

TO ERR IS HUMAN…

13 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Strategies and Tools to Enhance Performance and Patient Safety

Great technologies, Policies and Procedures are not the only factors in Patient Safety, Human Factors

Providing Excellent Care requires a Team effort

14 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

TeamSTEPPSExpert Team

Team of Experts

First Step: SPEAK UP

15 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Encourage the reporting of suggestions, compliments, or problems

Supervisor

Chief of Service, Medical Director

Charge Nurse, Unit Manager

Safety Check, Please

Unusual Occurrence Report/Patient Safety

Common Themes of CSAs

August 22, 2019 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.16

Most arise from system problems and not individual behaviors

– The majority have NO malicious intent

– Bad things happen to good people

Policies are already in place but not alwaysfollowed

– The core issue in drift

Importance of Learning Opportunities and recognizing exemplary behavior (Good Catches)

– Constructive vs. Destructive

– Second victim- usually the biggest advocate

– It is HOW we react to errors that determines whether we LEARN from them.

Swiss Cheese Model

17 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

18 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Strategies and Tools to Enhance Performance and Patient Safety

What is TeamSTEPPS

National Program developed by Department of Defense's Patient Safety Program in collaboration with the Department of Health and Human Services Agency for Healthcare Research and Quality

Scientifically rooted in more than 20 years of research and lessons from the application of teamwork and communication principles

A source for ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of your health care system

19 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

First Agenda

TeamSTEPPS Framework

Leadership Delegation, Facilitate Team Events (Briefs, Huddles, Debriefs), Conflict Resolution

Communication SBAR, call-outs, cross-checks, check-backs

Situation Monitoring: Awareness & Shared Mental Model

Mutual Support: Task Assistance, Feedback, Assertion, Conflict Skills (2 Challenge Rule, CUS), Collaboration

20 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Strategies and Tools to Enhance Performance and Patient Safety

Great technologies, Policies and Procedures are not effective if not practiced 100% of the time

21 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

40 yo female post right inguinal hernia repair, extensive Marcaine used at the surgical site due to patient’s low pain tolerance per history

General Anesthesia with LMA

Recovered well, upon discharge patient’s leg buckled

Documentation did not address if patient could bear weight or how she ambulated

Patient was kept for 30 more minutes and discharged

About 10 days later patient told PCP she fell in PACU after surgery

Case Study 1

22 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

65 yo Spanish speaking male in pre-op for colon resection surgery

Patient consent was in English and there is no translator available

General anesthesia

During intraoperative phase patient experience marked bleeding and required blood transfusions

Upon report to PACU, 1 more unit of blood was due and brought over by Anesthesiologist

Blood was hung, within 7 minutes patient began experiencing rigors and blood pressure began to drop

EMR showed patient was O+ and blood hanging was A+

Case Study 2

23 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

36 yo male was in pre-op for left rotator cuff repair.

Anesthesiologist at bedside to prepare for block

During infusion of local anesthetic patient experienced seizure

Patient was given versed IV and taken to OR for surgery

After surgery family was informed of seizure in pre-op

Case Study 3

The devil is in the details….DOCUMENT

24 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Nursing UOR-O (Unusual Occurrence Reports- Online)KP.ORG/UORO

25 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

Questions???

26 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019

keep our patients safe