• Establish a ‘culture of dissatisfaction’ – always be on the lookout and find all the ways to fail.
• Embrace the safe work-arounds, and measure their effect. We know that staff are remarkably creative at developing work-arounds, which exist largely because what we try to impose does not work. If the work-around is safe, learn from it.
• Standardize that which can be standardized, and nothing more; allow improvisation and adaptation; cultivate a culture where these adaptations are not ‘breaking the rules.’ Insist on discussing and learning from both standardization and adaptation.
• What appears safe and reliable is often an infrequent event just waiting to happen; “non-events” do not demonstrate that the system is safe.
• Two questions that leaders can ask of staff:
  • ‘Have you ever been in a situation where you couldn’t follow a policy/procedure designed to make care safe?’
  • ‘Have you ever been in a situation where you have had to manage off-service patients on your unit (e.g., orthopedic surgery patients on a neuro floor)? How did you manage to safely care for them? ‘ Carol pointed out that we wouldn’t want to put up a billboard saying “You’ll get safe care at our hospital…as long as you are only taken care of on the floor specific to your condition, and cared for exclusively by staff who take care of only patients with your condition.”

A concept Carol presented that opened my eyes is what I’ll call “safety creep” although its official name is “System Migration to Boundaries.” First, there is a right way of doing things: this is an expected ‘safe space’ of action defined by professional standards. For example, two nurses check each unit of blood before administering it, and one checks the patient’s ID band: this is the safe space of action.

Over time the behavior starts to creep over to the “illegal but normal” real life standards, aka usual way of doing things: when we’re busy, we still have two nurses check the bag, but it’s ok not to check the ID band (we know who are our patients are, right?).

Creep continues into the ‘illegal illegal’ or very unsafe space, with increasing chance of accidents. For example, now we don’t find a second nurse to check the bag, nor do we check the ID band. Most of us would call that ‘an accident waiting to happen.’ These are the circumstances where, when something bad happens, anyone can say in retrospect, “Why did they keep doing that? Didn’t everyone see how unsafe it was?”

One reason for erosion in safe practices is that as new staff enter this work environment, they are oriented not to the ‘safe space’ or right way of doing things, but to the ‘illegal but normal’ standards that are the practice in that setting. Thus they perceive these standards as the safe space of action, when in fact they are illegal but normal. Unless we continually work to move back to the expected safe space from the usual space, and orient/train to the safe space, we are allowing safety to degrade.

Best wishes for a safe and happy new year.

Thoughts? Share with me here…

Group 1

Concentrated on structural issues to support the two selected clinical topics—prevention of surgical site infection, and prevention of venous thromboembolism—what do we need to go forward? There is lack of coordination of topics at the state level—how do we take this work (of the Coalition) into the future, coordinate efforts, keep topics from fading from interest?

• Continue the core planning group, form Steering Committee and add other members (business community, consumer, etc.)
• Have a conference at least annually
• Steering Committee should take the recommendations and flesh them out within Washington, e.g., address geographic issues

Topic 1: Surgical Site Infection

• Link with the work of the national surgical infection collaborative work—perhaps Steering Committee can endorse
• Identify a return on investment (ROI) for preventing surgical infection
• Collaborative work will be the basis for ongoing measurement around this recommendation

Topic 2: Thromboembolism

• Interest group to meet in the summer, focus on continuum of care from inpatient to outpatient care; get Medicare Part A and B talking about it.
• Identify ROI for the recommendation.

Group 2

1. Consumer Education

• Reference JCAHO Speak Up and National Patient Safety Foundation (NPSF) documents for basic information to share.
• Share the above groups (JCAHO & NPSF) information with table members and get consensus then send the participants at the meeting for group input and consensus.
• Utilizing the numerous educational avenues listed on our flip chart information begin to spread the use of the new tool for Patient Safety In Washington State
• Engage physicians by educating at State-Wide meetings, as well as taking this to the medical schools to incorporate into their education process
• Engage nursing and other professionals through their educational offerings
• Continually reinforce the message like “Speak Up” on an ongoing basis utilizing the various tools for education – flyers/brochures in offices, DMV, Post Office, etc. Utilize TV, radio, and newspapers for Public Service Announcements (PSA’s), posters in hospitals and physician offices
• Teach physicians and staff to encourage the dialogue with patients and families – can utilize scripting as appropriate (i.e. can I answer any other questions for you?, here is a notepad to write down any questions you may have and when the doctor comes to see you I will help you get those questions answered).

Goals/timeframes:

Overall goal is to accomplish the information blitz within next two years.

2. Informed Consent

• With a more educated and engaged patient/family population the roll out of improving informed consent would be a natural flow
• Provide a source for evidence-based information to assist in the explanation of procedures and surgeries.
• Create education materials keeping in mind literacy issues and cultural diversities

Goals/timeframes:
Natural flow after initial first 12 months of above project

Group 3

The Foundation for Health Care Quality was volunteered by Dorothy Teeter, FHCQ CEO, for continued organizational and staff support.

Topic 1: Prevention of surgical site infection

• Goal: 95% of all patients get the right antibiotic
• How to achieve?
  • Within 6 months: establish a way for all hospitals to commit to participate
    • Identify the educational tool(s) and uniform data collection tool for hospitals
    • Establish the statewide baseline
    • Help hospitals improve performance
    • Establish data repository
  • Within 18 months: remeasuare

Topic 2: Improve consumer involvement in their care and safety

• Focus on polypharmacy
  • The State Coalition will support this effort
  • Target those over 50 years old
  • Use statewide information blitz

At 12 months: survey patients > 50 years – has anything changed? Plan followup activities

Group 4

Improve the capture of errors and events

• Non-alignment emerged around the potential use and misuse of data
• What are we doing to share our improvements: hospitals want to talk about the good things, and insurers and the State want to hear about the good things.
• Improve partnerships between insurers and hospitals
• Identify neutral third-party forum to share
• Use an existing user group – add consumer and payer perspectives; put out a newsletter so everyone can benefit.
• Hospitals/providers want some protection in the marketplace.
• Others want assurance that providers/hospitals are working aggressively to make improvements
• Payers would focus on evidence-based measures and support anonymous reporting.
• Summary: a voluntary collaborative to share information; collaborative would include providers, consumers, payers, et al.

Group 5

Patient safety relies on information, and need to get consumers involved: focus is on information to the consumer.

Develop Patient Safety Coalition

• Address the top three LeapFrog initiatives first, then broader issues.
• How?
  • Identify the Coalition
  • Align knowledge and constituencies
  • Want a common goal and focused goals
    • Who needs to be there? Who are the stakeholders?
    • Convene a neutral and time-sensitive body
    • Develop a single set of measures and priorities for the Coalition
    • Need ‘gain-gain’
  • Individual commitment
    • How to communicate better with hospitals
    • Share best practices & measures
    • Talk to hospital leadership, get buy-in
• In two years:
  • The LeapFrog initiative will have ‘gained traction.’
  • Physician leaders around patient safety
  • Patient-to-patient safety meetings?
  • Financial commitment
  • CEO commitment
  • Need steering committee and quarterly meetings

Group 6

1. Intensivists in Intensive Care Units

• The wording in the recommendation is overly-specific.
• Standard should be the “percent of hospitals who apply this to their ICU patients”.
• The Coalition needs to make itself known as an entity, then get a group to own the language around this standard, articulate it and its rationale.
• Talk to all of the interested parties about it, e.g, LeapFrog and the professional organizations that define ‘intensivists’ – take a ‘Walk in the Woods’ by February 200

2. Patients involved in their care and documentation

• The Coalition must be in existence and serve as champion: identify the groups that would be partners in this, e.g., consumers, AMA, WSMA, and facilitate that discussion; there is already some alignment of interests among the parties. Target date is Fall 2002.
• The role of the Coalition is to make sure this all happens.
• The measure will be defined by that group.

Group 7

1. Antibiotics and surgical site infections

• Each hospital adopts the CDC standard for defining what a surgical site infection is. (Possible resistance from hospitals that use their own definition of infection.) Target: 1 year
  • Evaluate which hospitals are using it
  • Determine why, if not using
  • Help hospitals adopt its use
  • Report who has adopted
• Eventual expansion of use of definition to other settings, e.g., outpatient surgery
• Develop best practices using hospital stakeholders using consensus process
• Implement best practice using various methods, e.g., statewide collaborative
• Consider peer-reporting of adherence to best practice (2 years) or public reporting (3 years)

2. CPOE

• So many stakeholders agree on it but big issue is funding – ultimately need to seek funding for acquisition.
• Six month goal: increase shared understanding among the stakeholders about barriers (a Walk in the Woods approach), then seek funding together.

Responses From Panel

Troy Hutson, Washington State Hospital Association:

• Great work; impressed with effort and the quality of the recommendations
• Leadership: how do we get leadership to continue?
• Need to be inclusive – get all stakeholders involved
• Voluntary collaboration – let’s build on what we know how to do, our willingness to work together, and use existing models for improvement, e.g. collaboratives, COAP
• Need to take that Walk in the Woods together with LeapFrog
• JCAHO, National Public Safety Foundation – how do all the efforts fit together?
• Strategic vision: let’s figure out how to use this structure to look at patient safety comprehensively, which will eliminate need to respond to multiple requests

Maxine Hayes, Department of Health:

• Very good use of her time
• DOH could provide leadership and use its voice in Olympia for advocacy
• Need to legitimatize the Coalition, then can assign work. All of the sponsors should commit to ongoing support.
• Part of the DOH’s mission is to assure patient safety, but can’t do it alone. All of our efforts are very interdependent.
• Will contribute their credibility to the formation of the Coalition.
• All sponsors want to be very supportive
• Recognized Mary Selecky’s presence today.
• DOH is not a purchaser but does have, for example, the Diabetes Collaborative expertise

Steven Seitz, Agency for Healthcare Research & Quality, User Liaison Program:

• AHRQ has been to five states dealing with state policymakers, and is working with LeapFrog is help some of the states get started
• Most states did ‘talking head’ events, but one had a pre-determined political agenda it wanted to advance: outcome of the event was “here’s what we are not going to do.”
• Other states’ work compared to Washington?
  • We have the better chance of getting something to actually happen
  • We started by dealing with the internal processes of the stakeholders – where do we disagree?
  • Many of our reports ended up pretty specific – they have ‘stickiness.’
  • Can consolidate all into an action plan

Hilton Seattle Airport & Conference Center

Our 10th regional conference focuses on the topic of “Safety in Transition.” Presentations by nationally-recognized speakers, breakout discussions in workshop formats, a poster session, and networking opportunities, provide a full-day event that will challenge participants’ assumptions about best practices, and provide tools and methods that can be quickly put to use in participants’ care settings. Topics may cover a wide range from safety during transition to electronic health records, to the effect of health care disparities on safety to patient identification during transfers and transitions, and much, much more…

Conference registrants are invited to a book-signing and lecture by Dr. Abraham Verghese, author of Cutting for Stone, on Monday afternoon, May 14 (4:15-6 p.m.) at the conference site, followed by a reception. Registrants will receive priority seating and complimentary parking.

Qualis Health will present its annual Awards of Excellence in Healthcare Quality again in 2012 at the Northwest Patient Safety Conference. The nomination submission process will open in January and the application form will be posted to Qualis Health’s website, see details. Information about the program can be found at www.qualishealth.org/healthcare-professionals/award-excellence-healthcare-quality.  Please share this information with other individuals and/or organizations who might like to apply for this award.

Here’s what participants had to say about last year’s conference…

• This conference day was terrific! And meaningful-I wish more people from my facility had been here.
  
• I have been inspired to move forward in a leading role after hearing Nancy Skinner speak on transitions.
  
• It renewed our enthusiasm to continue pressing forward and change our hospital culture, focusing on true patient centered SAFE care!
  
• There was lots of valuable information and examples that can be shared with staff to help initiate/guide patient safety efforts at workplace.

Featured Speakers

Keynote Speaker John J. Nance		The Emily Jerry Story Chris Jerry & Eric Cropp	Della Lin, MD

Would you like to join these speakers?

We are pleased to invite interested speakers to submit proposals to us for concurrent sessions at our conference. We seek experienced, dynamic, clear speakers who can present their experience with topics related to patient safety. Submissions related to ensuring safe transitions will be given priority; and we are interested in creative, participative sessions. If you’re interested, please download our call for speakers and return the form by February 10, 2012.

Or maybe you would like to submit a poster?

We invite poster submissions on patient safety-related topics. All topics are welcome; priority will be given to posters related to ensuring safe transitions. This is an excellent opportunity to share your success with our community! If you’re interested, please download our call for posters and return the form by March 16, 2012.

Get your organization noticed!

Show your support for our patient safety community and improving care for people in the Northwest by becoming a sponsor of this vital learning and networking opportunity in our region. Your financial contributions help ensure a successful event that continues to grow each year. Several contribution levels are available to fit organizations of any size. Check out our sponsorship package now!

Typically, though, there are suggestions of having nurses attend the safety committee so leaders understand what is happening on the unit. Leaders ask those nurses what they can contribute to preventing patient events and ask if practice matches the policies and procedures. Often we will hear the barriers they come across or what their wish list might be to assist with the success of reducing patient events.

That is great information, but not a true representation of how far the understanding has reached the front line staff.

One experience I can share is when I was rounding and talking to staff. I happened to ask a nurse about how she prevented her patient from falls. She was able to articulate the interventions and show how she documented fall risk, etc. I asked her how many falls her unit had in the past month and she was unsure. I asked her how many falls occurred house-wide last month and she said, “ Maybe two or three”? Her response indicated to me that she did not have an accurate understanding of the fall rate.

I proceeded to ask random staff on different shifts and realized the information reached management, but not necessarily those at the bedside.

Take your staff to the safety board and show them: “ Here are the data on falls, you will see a graph each month indicating how we are doing.” Don’t assume staff can read graphs. The data should tell a story that can be digested. Ask staff to use post-it notes to place suggestions for improving patient safety and affix them to the safety board. Find out what information they need to know. Look for gaps and then bring the information back to them.

Poor communication is a common cause of medical errors in healthcare. We need better communication about medical errors in order to work as a team to prevent them.

Patient Safety Culture Surveys:

• Getting good response rates can be a challenge – methods include the following:
  • Use of incentives: coffee gift card; entry into drawing for gift certificate.
  • Promote friendly competition among administrators.
  • Conversely, use no incentives, but create the expectation that everyone does it.
  • Use a combination of methods, e.g., paper and electronic surveys.
• More than one organization has seen a decline in overall patient safety culture grade after implementing TeamSTEPPS training, and this does not necessarily indicate worsening culture: the more people are aware of safety, the more they are aware of the gaps.
• Culture is climate-specific, so there can be significant variability at the unit level.
• “Handoffs Between Units” often is rated worse than teamwork within a unit. Rather than blame and point fingers, a way to address this is to for nurses to tour one another’s units and ‘walk in the other’s shoes.’ The staff are encouraged to take on the challenge rather than be directed by administration how to fix it.

Staff orientation and training:

• Use simulation and practice conflict in a ‘safe place’ (controlled environment) before taking it to a real care setting.
• One organization includes an hour on patient safety topics in the orientation for all new employees, with additional training for patient care staff on culture and system changes and human factors engineering, and a twice-yearly patient safety conference.
• The IHI Open School has many modules on human factors fundamentals and other topics.

Here are a few Patient Safety Pearls from the May 6, 2011 Patient Safety Network meeting…

Patient Safety Rounds or Huddles:

Anticipating challenges and work-arounds:

Use of Prescription and Over-the-counter Medications and Dietary Supplements Among Older Adults in the United States

Qato, Dima; Alexander, G. Caleb; et al, JAMA. 2008; 300(24):2867-2878.

Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States: The Slone Survey

Kaufman, David; Kelly, Judith; et al, JAMA. 2002; 287:337-344.

A Call to Action: Protecting U.S. Citizens from Inappropriate Medication Use

Institute for Safe Medication Practices,  2007

Annual Reports on Medication Use in the U.S. for Years 2004-2006

Slone Epidemiology Center at Boston University

FDA:  Medication Errors

FDA receives medication error reports on marketed human drugs (including prescription drugs, generic drugs, and over-the-counter drugs) and nonvaccine biological products and devices.

U.S. Pharmacopeia

As a service to healthcare practitioners, industry, consumers, and others, USP has developed a free tool for accessing drug names that have been identified with a medication error.

NCPIE:  The National Council on Patient Information and Education

Promotes the safe use of medicines through improved communication

The American Society of Medication Safety Officers

The mission of ASMSO is to advance and encourage excellence in safe medication use by providing communication, leadership, direction, and education among its members.

Look-Alike/Sound-Alike Drug Names

• ISMP:  Confused Drug names
• ISMP:  Error-Prone Abbreviations List
• ISMP:  Using TallMan letters

Patient Oriented Resources – Your Medicine: Be Smart. Be Safe.

The booklet provides important guidance for safe and smart medication management and includes forms to keep track of information. Also includes a wallet card.

• For English click here
• For Espanol click here