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© 2017 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Prepared for University of Arkansas for Medical Sciences by Healthcare Performance Improvement, LLC for limited, non-exclusive, non-transferable internal use only by University of Arkansas for Medical Sciences.

High Reliability Training

Behaviors for Error Prevention

© 2016 Press Ganey Associates, Inc.

Our Focus for this Session

Goal:Learn about reliability and safety initiative to reduce preventable harm to patients and employees at University of Arkansas for Medical Sciences (UAMS)

Objectives:At the completion of this session, participants will be able to:

1. Identify how errors occur and events happen2. Learn how to prevent errors3. Learn and commit to practicing the UAMS safety

behaviors to prevent errors

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Warm Up Exercise

1. Introduce yourself to your fellow table mates

2. Tell them where you work

3. Show them the picture of a loved-one or friend you brought in today

4. Tell them a little bit about that person and why you chose that picture


The Exceptional Experience:

• Don’t harm me

• Heal me

• Be nice to me

…in that order

Our Patients are all Somebody’s “Picture” Person

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FROM JANUARY 2015 - DECEMBER 2017…

Why Are We Here?

Steve M.Delay in Diagnosis

And Treatment

Kerry J.Hospital acquired infection

Baby MichaelMedication Event

Josh M.Medication Event;

Baby JohnDelay in

Treatment

Alan B.HAI

Steve M.Delay in diagnosis

and treatment

Anne C.Wrong body

part

464 Serious Safety Events / 35 deaths

Lynn S.Care Management

Barbara G.Delay in

treatment

Ian H.Retained foreign

object

Anthony D.Delay in

Treatment

Carol W.Wrong

implant

Betty G.Fall with fracture

Keith R.Suicide

Candace S.Procedural

error

Robin V.Care

management

Jim G.Fall with

hematoma

Mary A.Procedural

error

Dorothy T.Hospital acquired

condition

Joni F.Delay in

Treatment

Lori K.Stage 4 ressureulcer


High Reliability Organizations

3 Principles of Anticipation | “Stay Out of Trouble”1. Preoccupation with Failure2. Sensitivity to Operations3. Reluctance to Simplify interpretations

2 Principles of Containment | “Get Out of Trouble”1. Commitment to Resilience2. Deference to Expertise

HROs “operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.”

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Patient Harm – National Data


210,000-440,000patients, each year, suffer

from preventable harm that contributes to their death.

James, John, A New Evidence-based Estimate of Patient Harms… Journal of

Patient Safety, September 2013, Volume 9, Issue 3

44,000 to 98,000patient deaths per year

from medical errorsTo Err is Human, Institute of

Medicine (1999)

Harm in Healthcare“A 747 a Day”

Medical error—the third leading cause of death in the U.S.

251,000 preventable deaths per year.

Makary, M. and Daniel, M. (2016), Johns Hopkins

University School of Medicine

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Died after receiving organs that did not match her blood type.

Jesica Santillan

Hospitals can be Dangerous Places…


Safety is Everybody’s Business

Contract elevator maintenance employees drained fluid from elevators into containers used for surgical detergent. The containers were not properly re-labeled or securely stored. They were restocked and shipped as detergent back to Durham Regional Hospital and Duke Health Raleigh Hospital.

In November and December of 2004, the elevator hydraulic fluid was used as detergent in one step of a multi-step cleaning and sterilization process of surgical tools.

Photo Credit: Duke University Medical Center

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Harm in Outpatient Environment

Sebastian Ferrero – Medication Error

Darrie Eason – Misdiagnosis

Patrick Sheridan – Misdiagnosis


Josie’s Story

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Patient and Employee Harm

– Our Data

14 © 2018 Press Ganey Associates, Inc.

Serious Safety Event• Reaches the patient • Results in moderate to severe harm or death

Precursor Safety Event• Reaches the patient• Results in minimal harm or no detectable harm

Near Miss Safety Event• Does not reach the patient• Error is caught by a detection barrier

or by chance

PrecursorSafetyEvents

SeriousSafetyEvents

Near Miss Safety Event

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

A deviation from generally accepted performance standards (GAPS) that…

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15 © 2018 Press Ganey Associates, Inc.

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Serious Safety Event Rate (SSER)University of Arkansas for Medical Sciences

January 2015 - December 2017Rolling 12-month average of serious safety events per 10,000 adjusted patient days

Serious Safety Events (SSE) Serious Safety Event Rate (SSER)


Burning Platform

In 2017, on average, a patient somewhere in the University of Arkansas for Medical Sciences was seriously harmed every ?? days.

In other words…

Approximately 3 times per week a patient somewhere on our campus experienced a preventable event that resulted in significant harm or death.

2

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“How” Data (%) “Why” Data (%)People Causes UAMS HPI

Compare Systems Causes UAMS HPICompare

Knowledge & Skill 11.4 15.1 Structure (job design-resources) 10.2 10.7

Attention on task 22.7 11.4 Culture (people interaction) 69.4 53.0

Communication 6.8 9.6 Process (flow) 4.1 16.8

Critical Thinking 29.5 39.7 Policy & Protocol (on paper) 12.2 12.5

Non-Compliance 18.2 17.8 Technology & Environment 4.1 7.0

Normalized Deviance 11.4 6.3 Culture Preventable = 82.7 73.0N = 44

Fill Rate: 88%

Fill Rate: 53%

N = 49 Fill Rate:

92%

Fill Rate: 69%

Comparison based on 4,868 inappropriate acts from 120 sites in HPI CCA Database

Harm – How and Why Events Happen

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Why do Events Happen?The Swiss Cheese Effect

Adapted from James Reason, Managing the Risks of Organizational Accidents (1997)

Active Errorsby individuals result in initiating action(s)

EVENTS ofHARM

Multiple Barriers - technology, processes, policies and people - designed to stop active errors (our “defense in depth”)

Latent Weaknesses in barriers

PREVENT The Errors

DETECT & CORRECT The System Weaknesses


Patient develops

seizures after 4 days of elevated

sodium level and dies

2nd physician fails to identify cause of sodium level >180

Case in Point - Inpatient

Physician fails to follow up on missing lab result

Secretary fails to order lab test because order unclear

2nd nurse fails to note omission of order during shift change audit

Nurse fails to note omission of medication order in the computer

Pharmacist fails to note medication order needed to keep a patient from excessively diuresing (urinating)

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RN gives patient Bactrim prescription

Patient transported to ED 8 days later with INR of 8.5

and severe hemorrhage –patient died

Case in Point - Resident

Pharmacy Tech sees Warfarin interaction alert

but fills order anyway

Pharmacist clicks through Warfarin interaction alert when entering order

Resident orders Bactrim for patient on Warfarin


Common Causes of Past Events

We looked at past serious events at our hospitals to look for the common reasons why they occurred.

Common causes associated with our past events:– Lack of attention to detail

– Staff uncomfortable with peer checking

– Poor communication

– Lack of questioning attitude or critical thinking skills

– Non-compliance with policy, procedure, or expectations

• Including Normalized Deviance

Normalized Deviance is when a group doesn’t comply together – such that deviating from the norm becomes an acceptable way to practice.

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Reporting errors and events helps us identify system issues (holes in the cheese) that can lead to harm

The Importance of Reporting

How can we learn from errors if we don’t know how and why they are happening?

An HHS study indicates hospital employees recognize and report only one out of seven errors, accidents and other events of harm.

Typical reasons for low reporting are:• Fear (of retribution due to the lack of a fair and just culture)

• Burden (because the reporting system is too time consuming or difficult to use)

• Employees don’t recognize “what constitutes patient harm” that needs to be reported

• Staff assume someone else will report the event

• People think events are so common that they don’t need to be reported (yikes!)


Human Error Rate

Blame & Punishment(pre-1990)

Blame-Free(post-1990)

“Fair and JustCulture”

Our Commitment: Fair & Just Culture

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Human Error 101Understanding Human Performance

and how to prevent errors


Humans Work in Three Modes

1. Skill-Based Performance

“Auto-Pilot Mode”

2. Rule-Based Performance

“If-Then Response Mode”

3. Knowledge-Based Performance

“Figuring It Out Mode”

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Slip – Without intending to, you do the wrong thing

Lapse – Without intending to, you fail to do what we meant to do

Fumble – Without intending to, you mishandle or blunder an action or word

ERRORS WE EXPERIENCE

Stop and think before acting

ERROR-PREVENTION STRATEGY

Skill-Based Performance

What You’re Doing at the Time:Routine, frequent tasks in a familiar environment that you can do without even thinking about it – like you’re on auto-pilot

1 in 1,000 (0.1%) acts performed in error

(as good as it gets for a human working on their own!)


What You’re Doing at the Time:Responding to situations by recalling and using rules learned either through education or experience

Used the wrong rule – You were taught or learned the wrong response for the situation Educate about the right rule

Misapplied a rule – You knew the right response but picked another response instead Think a second time

Non-compliance – Chose not to follow the rule (usually, thinking that not following the rule was the better option at the time)

Reduce burden, increase risk awareness, improve coaching

ERRORS WE EXPERIENCE ERROR-PREVENTION STRATEGY

Rule-Based Performance

1 in 100 (1%) choices made in error

(not too bad!)

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Came up with the wrong answer (a mistake)

ERRORS WE EXPERIENCE

Stop and find an expert who knows the correct answer

ERROR-PREVENTION STRATEGY

What You’re Doing at the Time:Problem solving in a new, unfamiliar situation. You come up with the answer by:• Using what you know (parts of different Rules)

• Taking a guess

• Figuring it out by trial-and-error

Lack of Knowledge-Based Performance

30-60 of 100 decisions – that’s 30% to 60% – made in error

(yikes!)


• What if we could significantly reduce our errors?

• What if there were “more tools and fewer rules” -

fewer policies to fumble through?

• What if we came to work knowing exactly what is

expected of us?

• What if we felt empowered to fix a problem or voice a

concern related to safety?

• What if we could leave work feeling absolutely

confident that we delivered the best of care or services

to our patients as possible?

What If...

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“What Ifs” are Possible-through culture change

CultureShared values

and beliefs of individuals in a group or organization

But…Culture is not what you think, believe or feel – Culture is what you do.

Culture is demonstrated by actions – or behaviors. Things others can see – like the tip of the iceberg demonstrating what lies beneath.

Break

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Changing Culture through Actions:A Patient Safety Toolkit at UAMS to

Prevent Human Error and Events of Harm

Our UAMS Safety

Behaviors and Error

Prevention Tools

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Safety Behaviors to Prevent Errors



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What should we do?Ensure that we hear things correctly and understand things accurately

Why should we do this?• To prevent wrong assumptions and misunderstandings that could cause us

to make wrong decisions

Error Prevention Tools• Repeat & Read Backs with Clarifying Questions

• SBAR to transfer information (Situation, Background, Assessment, Recommendation)

• Phonetic & Numeric Clarification

Communicate Clearly

Effective Communications – it’s not what I say, it’s what you hear


Clear | Complete | Accurate

Sent and Received

Ha ha ha, Biff. Guess what? After we go to the drugstore and the post

office, I’m going to the vet’s to get tutored.

The Importance of 3-Way Communications

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When information is transferred...

1

2

3

Sender initiates communication using Receiver’s Name. Sender provides a request or information to Receiver in a clear and concise format.

Receiver acknowledges receipt by a repeat-back of the request or information.

Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication.

3-Way Repeat Back

A Safety Phrase:“Let me repeat that back…”

Train our ears to listen for “That’s Correct!” –it’s a codeword for “we understand each other”


The same as the Repeat Back, except…

The Receiver writes down the

information, request, or order

and reads back what they have written.

Don’t rely on your memory…write it down whenever you receive critical information that may be difficult to remember.

This is so important that The Joint Commission requires this for communication of critical test results, verbal orders and telephone orders

3-Way Read Back

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Ineffective Communication At Work


Clarifying Questions

Ask one to two clarifying questions:

• In all high risk situations

• When information is incomplete

• When information is not clear

Use the Safety Phrase:“Let me ask a clarifying question…”

Asking clarifying questions can reduce the risk of making an error by 2½ times!

Why… How…

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Letter Clarifications

For sound alike words and letters, say the letter followed by a word that begins with the letter...

A Alpha

B Bravo

C Charlie

D Delta

E Echo

F Foxtrot

G Golf

H Hotel

I India

S Sierra

T Tango

U Uniform

V Victor

W Whiskey

X X-Ray

Y Yankee

Z Zulu

J Juliet

K Kilo

L Lima

M Mike

N November

O Oscar

P Papa

Q Quebec

R Romeo

Adopted by NATO, International Civil Aviation Organization, Federal Aviation Administration, International Telecommunication Union, and US Nuclear Power Industry


Clarification Tips

Do you have to use that alphabet? No – but it’s a good best practice.

Use what you are used to, but use them in particular for the following:• Patient names

• Procedure or test names

• Medication names

Do you have to spell the whole word phonetically? NO! Spell those parts that can be confused:- “Neurology consult to room 405 – that’s neurology with an N as in

November”

- “I’m calling about Mr. Danes – starting with an D as in Delta”

- “Code Blue in room 330 B – that’s B as in Bravo”

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Number Clarifications

For sound alike numbers, say the number and then the digits

15…that’s one-five

50…that’s five-zero

45…that’s four-five

425…that’s four-two-five

4 to 5…that’s the range four dash five

…and always use leading zeros – as in 0.9


A Good Clinical Example

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SBAR to Transfer Information

An outline for planning and communicating information about a patient condition or any other issue or problem

Ensuring you say the highlighted words to build good structure in using the tool:

Introduction: Introduce yourself and who or what are you talking about

Situation: The bottom line (diagnosis, current condition, problem)

Background: What do you know? (medical history, past tests or treatments)

Assessment: What is happening now? (current findings, needs, concerns)

Recommendation: What is next? (recommendation or request for plan of care)

Always check to see if either party has any questions?

Bad ISBAR

Good ISBAR


SBAR – Your Turn!

• Situation: We need to practice communicating with SBAR.

• Background: In your learning packet you have a number of scenarios to practice giving and receiving the different elements that make up a good SBAR.

• Assessment: The scenarios are in the wrong order!

• Recommendation: Working in pairs, pick two or three scenarios and put them in the right SBAR order, then say them out loud to each other – making sure you say the words Situation, Background, Assessment and Recommendation before each item

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27

527

“The Same”

29

Epilogue: A Communications Failure


What are the barriers to using these tools in your unit or department?

• Break up into pairs

• Learning activities– Practice 3-way Repeat-backs and Read-backs, Clarifying Questions

and Letter/Number Clarifications

– Refer to the handout for case scenarios

– Take turns reading the scenarios and how you would use each of these tools to avoid communication errors

Communicate Clearly – Your Turn!

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It’s not about asking questions – It’s about questioning the answers!

Act on Concerns

What should we do?Think critically by questioning information we hear and see if it doesn’t fit with what we know

Why should we do this?• To detect incorrect information and assumptions that can lead to

erroneous decisions or actions• To help ensure work activities are stopped when faced with

uncertainty or unsafe conditions

Error Prevention Tools• Stop the Line when uncertain• Use ARCC to voice concerns (Ask a question, Request a change,

voice a Concern, use Chain of Command)

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STOPReview your plan. Resolve the concern. Reassess your actions.

Similar in concept to the “Stop the Line” or “Stop Work Authority” concept promoted by most high-risk industries

• If you are uncertain about what you are about to do…• If you have questions…• If someone raises a concern or question...

Stop the Line when Uncertain


“I have a Safety Concern…”

First, just Ask a question – in other words, offer a cross check

If that doesn’t work, Request a change – offer another alternative

Still no response? Voice a Concern – use the following safety phrase:

If no success, escalate up your leadership Chain of Command

Escalate Concerns Using ARCC

• We all have a responsibility to protect our patients and coworkers from harm.

• If you see or hear something that you think is a safety issue, escalate your concern in a mutually respectful manner.

• Assert yourself, but don’t be aggressive or rude. • Escalate using the following tips:

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“Cultural differences are a nuisance at best and often a disaster." Geert Hofstede, Emeritus Professor, Maastricht University

Power Distance

Geert Hofstede’s Power Distance• Extent to which the less powerful expect and accept

that power is distributed unequally

• Leads to strong Authority Gradients, which is the perception of authority as perceived by the subordinate

United States• Moderate to low

Power Distance (38th of 50 countries)

In Healthcare• High between certain professional groups:

• Some physicians and nurses

• Some nurses and other clinical staff

• Some leaders and staff


At a hospital in Virginia, a team member from Environmental Services was emptying trash from a patient room when a physician and a nurse entered to conduct an invasive bedside procedure.

The EVS person had been to Safety Behavior training and simply ASKED, “Aren’t WE going to do the timeout?”

The physician looked at the nurse and said “You know, she’s right, we need to do the timeout.”

GREAT use of ARCC to speak up for patient safety!

A “Speak up Using ARCC” Success Story

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Collegial Interactive Teams (CIT) = Tones + Tools

Setting the tone…

• “You had me at Hello”– Greetings – include first names

– Cordiality, openness

– Eye contact and body language

• Team goals– Use “we” and “us” vs. “I” and “you”

– What’s best for the patient…

• Invite a Questioning Attitude– Leaders set the tone for the flow of information

– “If any member of the team sees anything that is unsafe, I expect you to speak up...”


Tones

1. Smile and greet others by saying hello

2. Introduce yourself and explain your role

3. Listen with empathy and intent to understand

4. Communicate the positive intent of your actions

5. Provide opportunities for others to question

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• Break into small groups – 4 to 6 in a group

• Learning activities

- Practice ARCC it up (Ask, Request, Communicate a Concern, Chain of Command)

- Everybody in the group must participate in at least one scenario

- Refer to the handout for the case scenarios

Act on Concerns – Your Turn!

How can you use these safety tools in your unit or department?



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Respect, Reflect, Remind

What should we do?Look out for one another to catch each other’s mistakes while building a greater sense of accountability for our actions

Why should we do this?• To catch and trap honest errors before they reach our patients• To hold each other accountable for meeting practice expectations

Error Prevention Tools• Brief, Execute, Debrief • Team Checking / Team Coaching


Briefing Exercise

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Brief / Execute / Debrief in Naval Aviation

63

EA-6B Prowler Electronic Warfare Landing on U.S. Aircraft Carrier

Each and every flight is briefed to include safety and emergency procedures, providing situational awareness of the issues that could confront that day’s event. After the mission, the flight is debriefed to capture immediate

lessons learned to include areas for improvement.

Agenda Brief

Standard Operating Procedures (SOPs)Emergency procedures (EP)Contingencies

Execute AS BRIEFED

Debrief

Honest and introspective


Brief / Execute / Debrief

• Conducted for high-risk, new, or infrequent tasks• Everyone involved in the action participates• Facilitated by team member

BriefWhat we’re going to do…

ExecuteDo it…

De-BriefReview it…

5 points:

Roles and responsibilities

Procedure steps

What could go wrong, what are the signs, and how we would respond

Any lessons from past experiences

Error prevention techniques we will practice

Carry out the procedure according to the plan

Be a good wingman

“Goods and others”

What went well?

What could we have done differently?

Do we need to communicate any lessons learned to leadership for resolution or correction?

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Introduction Yourself and all team members

Patient Correct patient?

Purpose What we are doing and why

Plan Procedure steps – is there anything new or different?

Roles & responsibilities

Problems Any complicating issues or conditions?

Precautions What could go wrong, what would be the signs, and how would we respond?

Any lessons learned from past experiences?

Questions Ask for and encourage clarifying questions

Brief /


Perform the procedure, according to the plan

& Protect the patient and team

Check others and coach others

Speak Up for safety

STOP in the face of uncertainty & RESOLVEquestions and concerns

Execute /

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5:1 Feedback Plus – Delta:

+ What went well?

Δ What did not go as planned, and what will we do differently next time?

The Debrief is as important as the Brief!

Debrief


When to Brief / Debrief

• Successfully used in OR, OB and ICU

• Situations where it is most important:– Procedure is infrequent

– New person will participate

– Several ways to perform procedure

– Specific equipment is essential

– Procedure is complex

– Situation is critical

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Good News

It Doesn’t Take Much Time

Two studies timed Briefing/Debriefing: Study 1 – Timed activity at a mean of 3.5 minutes with range of 1-6

minutes

Study 2 – Mean of 2.9 minutes for the brief and 2.5 minutes for the debrief with a range of 1-5 minutes for each

It Saves Time 31% reduction in unexpected delays

16% reduction in communication breakdownsleading to unexpected delays

Nundy S, et al. Impact of Preoperative Briefings on Operating Room Delays.

Archives of Surgery. 2008;143(11):1068-1072


More Good News

Methodology

Preoperative brief similar to preflight checklists – consists of key questions regarding patient safety segregated by function, e.g. surgeon, scrub, anesthesiologist and circulator.

Four indicators of safety tracked – number of wrong-site procedures, attitudinal survey data, near-miss reports, and nursing turnover

Results

Wrong site surgeries decrease from 3 to 0 per year

Employee satisfaction increased by 19%

Nursing personnel turnover decreased by 16%

Perception of safety climate improved from “good” to “outstanding”

DeFontes, J and Surbida, S. Preoperative Safety Briefing Project. The Permanent Journal. 2004;8(2):21-27.

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1. Identify a medical task/procedure performed in a team environment. (Having a real-life case in mind works best!)

2. Name who in your group will play the lead physician. Everyone else plays team members

3. Simulate Brief / Execute / Debrief

Learning Lab ExerciseBrief>Execute>Debrief Simulation

Break

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1/1000 (my error probability)

x 1/1000 (your error probability)

= 1/1,000,000 (our combined reliability!!)

Two Heads are Better than One

Individual reliability is limited:1 defect per 1000 opportunities

We are better together…


Good teammates check each other

Team Check Each Other

Team Check = Watching out for each other • Teammates check each others’ work and are willing to be checked

Look out for your team members…• Offer to check the work of others

• Point out work conditions (hazards) your team member might not have noticed

• Point out unintended slips and lapses

• Say “Thanks for the crosscheck!”

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Poor Checking


Coach Each OtherThink Five to One Feedback

Encourage safe and productive behaviors

5 times as often as you…

Correct an unsafe and unproductive behavior

Tips• Be willing to give feedback to others…and be willing to have others

give feedback to you!

• Provide feedback based on observations

• Use the “lightest touch” possible

Remember – without saying a word:

“What you permit, you promote.”

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Coaching at its Best



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What should we do?Pay attention to the task at hand to avoid unintentional skill-based errors

Why should we do this?• To avoid those slips or lapses where the hand is operating before

the head• To reduce the chance that we’ll make an error when we’re under

time pressure, distracted or stressed

Error-prevention tools• Self Check Using STAR• Validate & Verify• Know Why & Comply

Engage for Excellence


Self-Check Using STAR

• Stop Pause for 1 to 2 seconds to focus our attention on the task at hand

• Think Consider the action you’re about to take

• Act Concentrate and carry out the task

• Review Check to make sure that the task was done correctly and that you got the correct result

STOP is the most important step. It gives your brain a chance to catch up with what your hands are getting ready to do.

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Conditions that increase the chanceyou will experience an unintended error when performing a familiar, routine task:

• Working under time pressure

• Doing multiple things at the same time

• Distractions

• Interruptions

• Boredom

• Mental or physical exhaustion

• Disorientation

• Just not paying attention

Any sound familiar???

STAR reduces your chances of making an

unintended mental slip or lapse by more

than 10 times...

STAR

Slap-Your-Head Moments


FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY

COMBINED WITH THE EXPERIENCE OF YEARS.

Count the Fs one time and one time only –Do not go back and count them again.

Read this sentence:

FINISHED FILES ARE THE RESULT OFYEARS OF SCIENTIFIC STUDY

COMBINED WITH THE EXPERIENCE OF YEARS.

Count the Fs

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Add the numbers….

Add the numbers. Say your answer as a group:

1000+ 40

+ 30+ 1000

+ 1000+ 20

+ 10+ 1000


And the answer is….

5000 ?

or is it…

4100 ?

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Let’s Check It Out….

+ 1000 = 4090

1000

+ 40 = 1040+ 1000 = 2040+ 30 = 2070+ 1000 = 3070 + 20 = 3090

+ 10 =

4100


The Myth of Multitasking

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REDGREENBLUEBLACKORANGE

BROWNPINKGREENREDBLUE

GRAYYELLOWBROWNBLACKPINK

REDGREENORANGEGREENYELLOW

BLACKBLUEGREENBLUERED

Source: Stroop, J.R. Studies of interference in serial verbal reactions. J. Exp. Psychol., 18:643-662, 1935.

The Power of the Pause - Say the color…


STAR – Your Turn!

• At your table, in 3 minutes, identify as many skill-based tasks that you perform at home and at work each day.

• As a class, discuss how you can use STAR in your unit or department to reduce skill-based errors.

Always use STAR as part of your day – it’s about adding intention when going from thought to action!

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Validate and Verify

Validate: Qualify the source and ask yourself, does it make sense to me?

Verify: Check it out with an independent, expert source

Patient

Technology

Professionals

Medical Record

Documentation Procedures & References


Get in the habit of asking these questions all the time –It takes only seconds

Validate: Internal check

Internal smoke detector…

• Does this make sense to me? Is it right, based on what I know?

• Is this what I expected?

• Does this information “fit-in” with my past experience or other information I may have at this time?

Expectation

Current Situation

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Verify: External check

When should you Verify?

• When your detector goes off

• In every high-risk situation

• When there is a change in the patient condition or plan of care

It’s OK not to know

It’s not OK not to find out


A Questioning Attitude Success Story

• Patient scheduled for MRI but had silver-impregnated central line catheter in place.

• MRI Tech wasn't sure if it was safe for the patient to go into the MRI. She stopped and thought about it – VALIDATE. Internal smoke detector went off because it didn’t seem right.

• She contacted her supervisor, who didn't think it was a problem and said go ahead and send the patient.

• She didn't think that was good enough so she found out who distributed the central line and called them. They weren't sure either but hadn't heard problems from any of their clients, so they said “go ahead.”

• Still didn’t think it sounded right so she found a way to contact the manufacturer, who advised her that the patient should NOT have an MRI because of the silver coating on the catheter – VERIFY.

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Know Why & Comply

93

What and Why - Use protocols and checklists to perform tasks reliably, safely, efficiently, correctly and to avoid reliance on memory.• Reference use - Protocols for tasks or processes performed by

memory, and typically by an individual. The protocol or policy could be referred to as needed. When was the last time you or your Team reviewed it?

• Continuous use – Lists, checklists, or flow sheets that list tasks or action steps for infrequently performed or high-risk or complexprocedures. How do you know you have the right revision?

When: Whenever available, especially for safety-critical actions. Don’t know, don’t go!


• Break up into in small groups – 4 to 6 in a group

• Learning activity– Practice Validate and Verify and Stop the Line using a

questioning attitude

– Refer to the handout for case scenarios

– Everybody in the group should read a few scenarios and talk about what they would do

Questioning Attitude – Your Turn!

How can you encourage others to exercise a healthy Questioning Attitude?

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What If?


We’ve Got to Know Them to Do Them!

What if…

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Next Steps

1. Commit to memorizing the four UAMS Safety Behaviors and Error Prevention ToolsThey are simple ideas but we need to create a common language around safety to reduce human error

2. Start using them todayEncourage your coworkers to use them, and start looking for situations when they did – or could have – prevent an error from occurring

3. Turn them into practice habitCollect and share Safety Success Stories – sometimes referred to as Great Catches - when you see them prevent harm


FROM JANUARY 2015 - DECEMBER 2017…

Why Are We Here?

Steve M.Delay in Diagnosis

And Treatment

Kerry J.Hospital acquired infection

Baby MichaelMedication Event


Baby JohnDelay in

Treatment

Alan B.HAI

Steve M.Delay in diagnosis

and treatment

Anne C.Wrong body

part


Lynn S.Care Management

Barbara G.Delay in

treatment

Ian H.Retained foreign

object

Anthony D.Delay in

Treatment

Carol W.Wrong

implant

Betty G.Fall with fracture

Keith R.Suicide

Candace S.Procedural

error

Robin V.Care

management

Jim G.Fall with

hematoma

Mary A.Procedural

error

Dorothy T.Hospital acquired

condition

Joni F.Delay in

Treatment

Lori K.Stage 4 ressureulcer

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80% Reduction…



Anthony D.Delay in

Treatment

Anne C.Wrong body

part

Mary A.Procedural

error


Thank Youfor your time today and for keeping our patients safe

We Want Your Thoughts…

• What did you like about the session today?

• What could have made this session better?

• What will you do differently tomorrow based on what you learned today?

Please complete and submit your evaluation form prior to leaving.

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