Patient Safety And Communications

Building Stronger Teams

Nazir Habib MD, ICUKaiser Vallejo

Objectives

• BACKGROUND: patient safety/medical errors

• Reasons for medical errors• Role of Teams in preventing errors • Building stronger teams• Understand role of “Human Factors”• Learn effective communication tools• Implement change in systems• Reduce erors

Medical errors

• 1999 report from IOM “to Err is Human”• Up to 98,000 patients die in hospitals from

errors ( 300 patients/day)• 5 million patients injured• Cost up to $38 billion• Consumers(leapfrog), • Media and lawyers• JCAHO priority

Media attention

Extent Of Medical Errors Weingart. BMJ VOLUME 320 18 MARCH 2000• 5th leading cause of death in USA• Exceeds deaths from MVAs, breast cancer or

AIDS• 2-5% Hospital admissions• Annually deaths exceeds deaths in Vietnam

and Korea combined

Comparison: annual deaths

Definitions:• Adverse event is an injury caused by

medical management and not the illness. Most due to error or hazardous environment.

• Error is an unintended act that does not achieve the intended outcome.

• Near miss is event that could have caused an adverse event.

• Sentinel event is an unexpected event leading to death or serious injury.

Patient Injuries: 5 million lives (IHI.org)

• Medication errors• Missed treatment and Dx/delays• Falls and injuries, HAPU• Delirium and confusion• Infections: Nosocomial or hospital acquired:

• IV and central lines• Pneumonia (HAP) or VAP • Surgical sites/wound • C. Diff infections at epidemic level• UTI from foley• Pressure ulcers

Nosocomial Infections

• 5-6% hospital admissions• Surgical, bloodstream, pneumonia and UTIs:

2 million/year• Causes 100,000 deaths• 30% are preventable• Increase length of stay and cost• Resistence: VRE,MRSA,DRSP, pseudomonas

Medication Errors

Accident Causation

Accident

Attention

DistractionsIncomplet

e

Procedures

Inadequate

TrainingDeferred

Maintenance

Defenses

Psychological

Precursors Unsafe Acts

Organization

Team

Individual

Technical

Tri

gg

ers

LatentFailures

Clumsy

Technology

Modified from Reason, 1990

Human Factors and Patient Safetywww.patientsafetyfirst.nhs.uk

• Human factors encompass factors that can influence people environment and their behaviour.

• Complex interaction of psychological and social factors and work environment that will impact outcomes, attitudes, morale and team work

• Individual characteristics/organization structure, leadership culture and system process which influence behaviour at work.

Causes of Errors

o Excessive professional courtesy. Hierarchy .. team members fail to point out deficiencies in performance or systems.Halo effect— clouds our judgment.

• Passenger syndrome—Team members experience “passenger syndrome” (“just along for the ride”) when they abdicate responsibility …someone else is in charge.

• Hidden agenda..Personal gains not team or patient • Complacency: individuals and teams lose their

vigilance and situation awareness. • High-risk phase—a procedure or time in which a

medical mishap is likely to happen (e.g., shift change).

• Task (target) fixation. Performance and time issues

Define Communication….

• Communication is the exchange of information between 2 people, groups, or entities.

• The word communication encompasses many types of exchanges, such as verbal and written….

• Consider body language, facial expressions, tone, eye contact….80%

• The biggest problem with communication is the illusion it is taking place ……GB Shaw quote

Communications/ Human Factors

• Poor Training/skills/competence• Fatigue/Overwork/Staffing level• Processes eg.Hand-0ffs • Distractions• Punitive culture/fear• Hierarchy• Intimidation• “Who is a right” vs “Doing the right thing”• Personal agenda vs TEAM..

Have Overworked Staff..?

Critical Events: Case Presentation

• 65 yr male is 3 days post-op colectomy on a PCA morphine pump.

• PMH: Obesity BMI is 40, DM– 8 pm exam: Temp 101 F, RR 28, O2 sats

93%, HR 120, BP 94/58• Which vital sign is most important predictor of

critical illness?• ?Could this patient die before 8 am???• What is your assessment?• What will you communicate to the MD?

Can We Predict Clinical deterioration?

SAFE Zone

“RED Zone”

“Dead Zone”

Slippery slope.. How do

you know?

INDEPENDENT PREDICTORS OF MORTALITY AT HOSPITAL DISCHARGE (Buist et al, Resus 2004)

• OBSERVATION/EVENT

• RR < 6/min• RR > 30/min• LOC change

• SaO2 < 90% • BP < 90 mmHg

• ODDS RATIO ( 95% CI)

• 12.3 (2.2-69.6 • 6.5 (3.6-11.8)• 6.6 (3.1-13.9)

• 2.6 (1.7-3.9)• 2.5 (4.6-7.4)

04/19/23 21njh

Who is watching the patient..?

Vital Signs Deteriorating…?

Vitals are vital!!!

JCAHO : Safety Goal Rescue patients

• 5-10% patients on the floor deteriorate after admission

• Which physiological parameters predict a deterioration in patient or impending code blue?

• Often in the first 24 hours• Often failure to recognize severity of illness• Failure to stabilize the patient• Poor or Failure to communicate is the most

COMMON reason for error • >50% patients care is suboptimal• MAJORITY code blues are preventable

Do We Have A Plan..?

MEDICAL EMERGENCY TEAM..?

ACUTE CHANGES IN: PHYSIOLOGY

AIRWAY

BREATHING

CIRCULATION

NEUROLOGY

OTHER

Respiratory DistressThreatened Airway

Respiratory Rate >30/minRespiratory Rate <6/minSaO2 <90% on Oxygen

Difficulty speaking

Systolic Blood Pressure <90Despite treatmentPulse Rate >130

Any unexplained decrease inlevel of consciousnessAgitation or delirium

Repeated or prolonged seizures

Concerned about patientUncontrolled pain

Failure to respond to treatmentUnable to obtain prompt assistance

MET CRITERIA

Results

• Reduction in Adverse outcomes:– Respiratory failure 79% (75 vs 15)– Stroke 78% (19 vs.4)– Severe Sepsis 75% (18 vs 4)– Renal failure 88% (27 vs 2)

»ICU admissions reduced 44%: only 8 pts. Transferred to ICU

Primary Survey:Brief!

• Examination•First --Brain:

LOC ? Neuro?•Airway/

Breathing RR and WOB , O2 sats!

•Circulation: BP, extremities

Secondary Survey

• Examination–Respiratory–Cardiovascular–Abdomen and genitourinary tract–Central nervous system–Peripheries

• Data: Medications, procedures,PMH,allergies etc

• Trends : vitals and labs…. • GET ALL the information before you

call…..!!!!!

How Do Your Doctors and Nurses Communicate..?* Differences in the style of communication?* Inadequate training and coaching* Role of Simulations ?* Organization Culture ? Level of

empowerment of frontline staff? Leadership?* Level of mutual respect?* Poor past experiences? Feedback

constructive and trended..?* Expectations not set-feedback regular?* Perceptions of teamwork?

Behavior : Intimidation Problem

• The Joint Commission also introduced a new standard in 2009 (LD.03.01.01) requiring accredited organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior.

• Develop a system to detect and receive reports of unprofessional, disruptive, and intimidating behavior

• J Nurs Care Qual. 2009. 24, No. 3, pp. 184–188 D.Nadzam

Physician Nurse Communications

• IDENTIFY physician by name. PATIENT by name!!NOT ROOM NUMBER please, USE I.SBAR• Have patient information and the chart readily

available.• Clearly express any concern about the patientand the reason for that concern.• Recommendation. Questions• Focus on the patient problem, not extenuatingcircumstances.• Be professional, not aggressive.• Read back , ask questions to clarify , use judgement

Communicate Crisis Clearly…..

• Situation: I am calling about patient…why?

• Background: Why is the patient in hospital? PMHX? Meds?

• Assess: Severity of acute physiology– Look at data, gather all

information.– ASSESS pt. Look at the

trends..what do you think?

• Recommend: intervention, test….?

SBAR ?Focused

SBAR focus

Assertion

Novice to Expert

CompetentAdvancedBeginner Proficient ExpertNovice

Technical Skills

Teamwork & Communication Skills

JCAHO: Failure /Barriers

• Lack of awareness/priority• Culture of blame and punitive action• Hierarchy• Failure of communication• Leadership not involved- Departments work

in silos• Poor structure for quality improvements• Outmoded information systems• Poor understanding of system or issues• No data

Medical Culture- The Upside

• Best and Brightest• Brutal Training- Elite Cadre• High Personal Standards• Amazing Work Ethic• Great attitude-want to do a good job

• Best and Brightest• Brutal Training- Elite Cadre• High Personal Standards• Amazing Work Ethic• Great attitude-want to do a good job

Predicts nurse stay…

Job Satisfaction- I like what I do, OR Teamwork- I like to be on with MD/RN?RT?

…. Top 3 predictors of nursing turnover:

Doctors and nurses work together as a team I can speak up if I disagree with physicians Disagreements in this unit are resolved with what is

right for the patient Open learning environment-ok to challenge concepts

“We have always done it this way” Learn together….

Job Satisfaction- I like what I do, OR Teamwork- I like to be on with MD/RN?RT?

…. Top 3 predictors of nursing turnover:

Doctors and nurses work together as a team I can speak up if I disagree with physicians Disagreements in this unit are resolved with what is

right for the patient Open learning environment-ok to challenge concepts

“We have always done it this way” Learn together….

“The Take Home

Messages” Learning environmentCommunication is very importantGet ALL information togetherKnow your patients..readMake rounds with the doctorASK questions, engaged and interested LEARN something new daily/ reading Build better teamsHave Fun……with medicine!

We can work as ….Teams

• Knowledge /Skills/Training – Key factor and is the

foundation of strong teams

• Attitudes– Team focus, collaboration– Behaviour – Communication

• Performance– Task – Safe practice– Application

Identifying Opportunities to Use Team Building Tools and

Strategies

Exercise: Role playing

• SBAR Technique• Break into groups of 6 = Case presentations• Diabetic with pneumonia BS is 40• 70 yr female Fx hip is confused on day 2 • 60 yr post op colectomy Hg is 9.2 at 6 pm• Patient on heparin drip for PE has BP 85/50 and HR

120 /min– Evaluate case/Present case use SBAR =call MD– Sign out patient to next shift or Break – End of shift– GOALS of care

Exercise: Patient is altered ??

• 65 yr obese DM, female is admitted to the floor with a stroke

• On day 3 the patient is more tired and husband calls you at 7 pm

• On your evaluation the patient is barely arousable

• Temperature is 101, BP 180/100, RR 20 shallow• O2 sat 92 on 2 liters,HR 120 sinus• Chest rales• What do you do BEFORE you call the doctor?

The End……Review sources.

• IHI .org• AHRQ• TEAMSTEPPS• AACN articles