Patient Safety Its the Way WeCare Buffy Key

Patient Safety Its the Way WeCare Buffy Key

Patient Safety Its the Way WeCare Buffy Key Sr. Vice President, Quality and Operations Cookeville Regional Medical Center Cookeville, Tennessee 1 Exceptional Care to Every Patient Every Day Building Healthier Communities 247 bed regional referral center Located in Cookeville, Tennessee Serves 14 county region of over 350,000 residents in upper Cumberland Region of Middle Tennessee 60% Medicare population

2 Exceptional Care to Every Patient Every Day 52,503 Emergency Room Visits 1,504 Newborn Deliveries 162,39 8,049 2 195 2,21 4 Outpatient Visits Physicians Surgeries Employees

12,893 Inpatient Admissions 3,954 Heart Procedures 16 9 Volunteers 3 Exceptional Care to Every Patient Every Day Isnt Healthcare Safe? IOM Report 1999 upIOM to 98,000 Reportpeople 1999a year because of medical updie

to 98,000 people a year mistakes in hospitals die because of medical mistakes in hospitals To Err is Human report - report IOM - IOM To Err is Human Medical Errors - 2017 10% of all U.S. deaths are now due to medical error 3rd highest cause of death in the U.S. is medical error Medical errors are an under-recognized cause of death John Hopkins Study, 05/3/16 Unwarranted variation is endemic in health care. Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in health care. Research on preventing medical errors from occurring is needed to address the problem. Martin Makary, MD, MPH, - Professor Surgery at Johns Hopkins University School of

Medicine, authority on health reform 4 Exceptional Care to Every Patient Every Day Our Safety Imperative GOAL AIM FOR ZERO Build Systems to prevent variation and errors for patients HOW? LEAN Thinking Principles Root Cause Problem Solving Preventing Errors and Harm 5 Exceptional Care to Every Patient Every Day Leaning Thinking Principles

Waste, quality, and safety Value Pursue IDEAL state Principle Examples Have the courage to identify the wasted steps (DOWNTIME) that may need to be eliminated in a process to achieve the best quality/ safety outcome Valuable vs Non-valuable steps Dept. Role Value Add Non-Value

OR Surge on Operating on a patient Waiting for procedure to start Inpatient Unit Nurse Administration of Meds Copying information from one computer system to another To achieve IDEAL, what should the process look like? 6 Exceptional Care to Every Patient Every Day

Cultural Obstacles shift from naming, blaming, and shaming to learning from errors, using knowledge gained to prevent future errors perceptions about medical errors; providers may view as individual issue rather than a system issue leadership may even publicly criticize their own organizations saying is there is no excuse for such errors Violations and Errors, Lapses, and Slips violations (intentional and avoidable) 27.6% of all adverse events errors (lapses mental errors) slips physical errors 7 Exceptional Care to Every Patient Every Day Root Cause/ Event Analysis Problem Solving Ask Why Instead of Who Finding Root Cause by using 5 Whys

Three Most Common Problems - In Problem Solving 1. Assuming you know what the problem is without actually see what is happening 2. Assuming you know how to fix a problem without finding out what is causing it 3. Assuming the action you have taken to fix a problem is working without checking to see if it is actually doing what is expected 8 Exceptional Care to Every Patient Every Day Preventing Errors and Harm The Science of Improvement Moving beyond Blaming Individuals Darrie Eason Case Create Quality at the Source via Error Proofing Make it Harder to Create the Error Make it Impossible to Create the Error SIGNS may not work! Saying be careful may not either! EXAMPLES OF ERROR PROOFING: 1. Banned Abbreviations 2. CPOE for handwriting error

3. Pre-surgical verification, marking the site, time-out process 4. Stopping the Line 9 Exceptional Care to Every Patient Every Day Conclusion SUGGESTED FACTS: Hospitals are full of Be careful Smart, conscientious employees yet errors and patient harm still occur. If telling people to be careful were effective, we would have already eliminated quality and patient safety problems! Always asking

Error proofing is a mindset that we have to adopt always asking why the error occurred. 10 Exceptional Care to Every Patient Every Day Community Impact Impact the welfare of the Community Build a healthier community Provide exceptional care to every patient every day 11

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