Systems Approaches to Safety

=Objectives, lecture 1=

List and describe the 2010 National Patient Safety Goals published by the Joint Commission.

 * Identify Patients Correctly: Use 2 ways, such as name+date of birth.  Do before any procedures, treatments meds, etc.
 * Improve staff communication: Especially getting critical lab info to correct person in a timely manner, improve communication between ER & ICU, etc.
 * Use Medicines safely: Label all medicines, take extra care with pts. on anticoagulation therapy. No concentrated KCL, etc.
 * Prevent Infection: Hand hygiene.  Prevent transmission of drug resistant organisms, surgical site infections, and central line associated infections.
 * Check Patient Medicines: Reconcile medications after changes, hospitalizations, etc. Check medications for interactions, give a list to patient, make sure patient understands regimen, provide updated list to PCP/other providers.
 * Identify patient safety risks: Especially suicidality, fall risks, etc.
 * Universal Protocol: Prevent wrong site, wrong patient, wrong site procedures.  Perform time out.

Differentiate between a “no blame” culture and that of physician accountability. Describe circumstances where one is one more appropriate over the other?

 * A “no-blame” culture acknowledges that most errors are committed by “good, hardworking people trying to do the right thing.” It seeks to increase reporting rates of errors for the purposes of data collection and analysis, leading eventually to improvements in the system to prevent such errors in the future.


 * Physician accountability describes the need for accountability and punishment when errors are willful, negligent, or egregious. Additionally, it describes the need for penalties in situations where the behavior in question is widely viewed as unacceptable (for example in the case of poor hand hygiene).  That is, providers habitually/willfully fail to comply with clear best practices, despite education, counseling, and system improvements (ie gel outside pt. doors).

==List five abbreviations which are prohibited at OHSU==

Describe Reason's swiss cheese model of system safety
Accidents occur when latent failures in a system overlap and fail to arrest or compensate for an active error. Probability predicts that eventually the holes of the swiss cheese (symbolizing both latent or active errors) will align and an accident will result. The theory is important because it concludes that errors are not unpreventable one-time events, but can be predicted and prevented.

List the five properties of organizations with a climate of safety.
From the “To Err is Human”:
 * 1) Provide Leadership,
 * 2) Respect human limits in process design
 * 3) Promote effective team functioning,
 * 4) Anticipate the unexpected,
 * 5) Create a learning environment

Describe the Universal Protocol
to ensure that a given procedure is what the patient needs and that it is performed on the right person, right site. Includes 3 checkpoints:
 * 1) Preoperative verification of procedure and background information
 * 2) Site is marked by person doing procedure (ideally with patient participation).
 * 3) Perform Time-out: Involves entire team.
 * 4) *Patient ID, side/site/procedure agreement, availability of equipment/personnel, any special considerations.