Patient Safety Literature Review

Chasing Zero: Can Reality Meet the Rhetoric?

2010-05-14T18:07:00.000-07:00

Charles R. Denham, MD; Peter Angood, MD, Don Berwick, MD, MPP, Leah Binder, MA, MGA, Carolyn M. Clancy, MD, Janet M. Corrigan, PhD, MBA, and David Hunt, MD, FACS

Healthcare-Associated Infections (HAI) are a daunting problem. Despite the advances in Patient Safety, HAI's have moved from the eighth leading cause of death to the third. Healthcare leaders from quality, purchasing, and certifying sectors convened at a national leadership meeting to address the issue of HAI's. The meeting was deemed "The Quality Choir: A Call to Action for Hospital Executives." The team concluded that every hospital leader must re-evaluate the strategy, structure, and function of their infection control and prevention services toward a goal of zero HAI's.

"Can the reality meet the rhetoric - can we really get to zero healthcare-associated infections? What is their perspective on the power of harmonization (the synchronization of the specifications of measures, standards, and practices down to the detailed level)? Is it a catalyst to performance improvement?" These are the questions that the committee addressed at the summit. Leaders from the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid, the Leapfrog Group, and the Joint Commission have established a call for action for every hospital CEO to join forces and establish a Chasing Zero Department (CZD) in their facilities.

TMIT will be launching an initiative to help design the necessary structures for CZD's throughout 2010. For more information on this initiative, go to www.safetyleaders.org. Watch the webcam on "Chasing Zero: Winning the War on Healthcare Harm" as Dennis Quaid and other families share their stories of medical errors and efforts to improve patient safety.

A Roundtable discussion, "Chasing Zero: Behind the Scenes" with individuals in the documentary is scheduled on Thursday, May 20th through the Librarians and Patient Safety website. Log on to libptsafety.ning.com and register to participate.

~ Denise

An article from the Journal of Patient Safety, Volume 5, Number 4, December 2009

Leading the LEAN Enterprise Transformation

2010-05-10T18:07:00.000-07:00

"Leading the LEAN Enterprise Transformation" by George Koenigsaecker

From my good friend Scott...

George Koenigsaecker is, in my opinion, the most qualified LEAN expert in the entire United States. George is recognized as one - if not the most - qualified CEO's in America to have driven LEAN through many organizations. His book holds many keys to LEAN enterprise transformation.

Here are some key comments on his value:

"Koenigsaecker has been one of the most important mentors for me on our LEAN journey. His willingness to share his knowledge and experience with the ThedaCare team has been invaluable." John Toussaint, CEO ThedaCare Center for Healthcare Value

"Koenigsaecker has spent more time transforming organizations into LEAN enterprises than any other CEO. In this brief volume, he summarizes his 30 years of experimentation by describing LEAN, showing how to measure it, explaining the role of the value stream analysis and kaizen, and publishing a tactical and strategic action plan for transformation." Jim Womack, Chairman and Founder, LEAN Enterprise Institute

Here are a few interesting comments from his book:

1. LEAN is designed to work on work - no matter what the work is. Sixty percent of Toyota Production System (LEAN) actually came from Henry Ford's Production System.
2. Humility is a key characteristic of successful change agents - if you're not humble, you can't learn.
3. You cannot see all the waste when first looking at a value stream - follow the '5X Rule' and revisit each value stream. You will unveil more waste each time; after five times, 90 percent of the waste will be gone.
4. The True North performance metrics are quality, time, cost, and human development; the most important is human development.

This book is for the serious Healthcare Leader who is really interested in driving a LEAN Enterprise Transformation throughout their organization.

~ Thanks again Scott!!

You can email Scott at brubakers@simpler.com.

Why Hospitals Should Fly [Guest Review]

2010-05-03T17:46:00.000-07:00

"Why Hospitals Should Fly" by John Nance

I received a guest book review by Bradley Truax, MD. Dr Truax is a Healthcare Consultant. You can contact him through his website at http://www.patientsafetysolutions.com/.

Here are some excerpts from the book review that is posted to their website:

["Since the late 1980's we have used the aviation industry as a model for patient safety and many valuable lessons learned from aviation tragedies that can be applied to healthcare. Everyone involved in patient safety realizes the rapidly growing numbers of effective measures that have been demonstrated to minimize errors and improve outcomes. But we have all been disappointed at our overall inability to significantly reduce the number of patients being harmed annually in whom adverse outcomes were potentially avoidable.

John Nance's new book "Why Hospitals Should Fly" really hit the target. While Nance masterfully weaves many best practices from IHI, NQF, AHRQ, Joint Commission, ISMP and others into his fictional "St. Michael's," his theme is that we have failed because we have failed to convert to a culture of safety. That basic theme is that "culture kills strategy every time."]

["Nance then demonstrates through the eyes of a physician visitor to St Michael's all the lessons learned from aviation that were applied to healthcare and changed the culture to one of "total, egoless support of the common goal (taking safe, effective care of our patients)" in a system in which the whole team acknowledges that errors will occur and the team will catch each other's mistakes before harm comes to patients. It is a high reliability organization and a learning organization in which all members take pride in learning from their mistakes as much as celebrating their successes. It is a culture in which teams are empowered and encouraged to do a root cause analysis on the spot and make changes to the system immediately (ala Toyota/lean thinking concepts)."]

["So do we think Nance's "St. Michael's" is achievable? Can it be done overnight? Do we have to wait for a new generation of healthcare workers? The question should not be "can it be done?" We simply must do it."]

For a look at the complete book review, log on to Dr Truax's website: http://www.patientsafetysolutions.com/.

The Checklist Manifesto: How To Get Things Right

2010-05-01T20:15:00.000-07:00

"The Checklist Manifesto: How To Get Things Right" by Atul Gawande

I have a very good friend named Scott Brubaker that is a LEAN Sensei for the CEO of Denver Health. [For all of you that are unfamiliar with the term LEAN, it is a process improvement method which identifies waste through such tools as value stream analysis and rapid improvement events. It's an awesome Patient Safety tool. You can learn more about LEAN concepts at www.simpler.com]. This is one of Scott's favorite books.

"This is the most impressive book I have read that integrates LEAN principles into healthcare. Written by a doctor that worked with the World Health Organization, the message and the outcomes will change the way you view your healthcare responsibilities... A MUST READ!" ~ Scott

Here is an excerpt from the introduction:

"Here, then is our situation at the start of the twenty-first century: we have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hard working people in our society. And with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating across many fields - from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy - though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technology.

It is a checklist."

You can contact Scott at brubakers@simpler.com.

Code Blue Preparedness

2010-04-21T18:59:00.000-07:00

Hello everyone!

I am posting an article on our Mock Code Training Program that was published in the Texas Board of Nursing Newsletter, April 2010. I am very proud of my nurses and their seemingly untiring efforts at Patient Safety. Here is the article:

Code Blue Preparedness
by Denise Hetman, RN

Code situations in any unit of a hospital are stressful. In order to ensure safe patient outcomes, many large hospitals utilize simulation scenarios and mock code drills to train staff (Lester, Jackson, & Masse, 2008). The South Texas Spine and Surgical Hospital has found a resourceful and effective way for their staff that play vital roles in code situations to receive the training necessary to ensure successful outcomes during emergent situations. Monthly training (announced and unannounced) in mock code drills is held. During the drill, team members are assigned badges to experience different emergency roles. Badge titles include: Chest Compressions 1, Chest Compressions 2, Team Leader, Medication, IV Nurse, Lab, Airway, Defibrillator, and Recorder. Non-clinical personnel may participate as runners that support the Code Blue Team. These individuals may assist by calling respiratory therapy, transportation, the patient's provider, or completing transfer forms. If they are certified in CPR, they may also assist with chest compressions. Team members rotate through several different roles during the event. Trainings conclude with an open discussion of the team's performance and an opportunity to provide feedback to the instructors. Nurses on guard in code situations have a duty to be prepared to institute appropriate interventions that are required to stabilize a patient's condition and prevent complications.

The Best Practice

2009-11-12T14:50:00.001-08:00

Hi Everyone!

Tonight I am pleased to post the first guest book review!! I hope that anyone interested in sharing their favorite Patient Safety book will submit a review of their own. I thought it would also be fun to post pictures of the guests and any contact information that they feel comfortable sharing. That way, we can use the blog to network as well.

Our first guest is Scott Chittenden from Yokota Air Base, Japan. Scott is the Patient Safety Officer at the hospital on base. His email address is: scott.chittenden.ctr@yokota.af.mil. Here is Scott's review of his favorite Patient Safety book, "The Best Practice" by Charles Kenney:

"This book helps readers understand the complexities in healthcare, the culture, and why the number of sentinel events are staggering. Leaders in healthcare improvement like Don Berwick, MD and the innovative approaches the Institute of Healthcare Improvement has made give hope and inspiration for the reader."

Thanks Scott!!

Josie's Story

2009-10-29T16:41:00.001-07:00

Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe by Sorrel King

Wow... I could not put this book down!! Every Patient Safety Director should read this book! Sorrel allows you to put your arms around Josie and her family - and see a tragic medical mistake from the family's perspective. You will be amazed at her strength and determination. It will make you want to be a better Patient Safety Advocate.

"King is an extraordinary woman, who took a paralyzing event- the medical accident that killed her 18-month-old daughter, Josie- and turned it into a national crusade. She transformed herself from having every intention of taking down the mega-hospital, Baltimore's Johns Hopkins, where, by every estimation, little Josie should have received top-notch care, to working with the facilities doctors, nurses, administrators, and even their lawyers to create a system that would eliminate medical errors. It wasn't easy. After she had watched helplessly, with doctors ignoring her pleas for help, while Josie deteriorated before her eyes, her grief and rage were nearly all consuming. The family hired a lawyer but Hopkins offered a settlement before a lawsuit was filed. But sometime between the investigation and the settlement, she had an epiphany. Wherever such revelations originate, it made her resolved to use the settlement money to create the Josie King Foundation, dedicated to the elimination of the nearly 100,000 deaths per annum caused by medical mistakes. In this moving, never preachy or strident memoir, she recounts Josie's experience, the evolution of the foundation, and the principals of the so-called Comprehensive Unit-Based Safety Program (CUSP) in practice today in hundreds of hospitals, thanks to Josie and her mom."
-Donna Chavez

It's definitely worth the time to read.

Visit the Josie King Foundation at www.josieking.org. There are books, articles, a DVD, a nursing award opportunity, ideas on Rapid Response Teams and Sorrel's speaking engagement schedule and more.

2009-09-29T18:34:00.000-07:00

Whack a Mole: The Price We Pay For Expecting Perfection by David Marx.

Whack a Mole is a game in which we watch the moles pop up and then we bop them in the head with a hammer... Whack a mole.

The author, David Marx is a systems engineer with a juris doctor in law who has spent his adult life "helping others reduce the risk imposed on us all by our shared human fallibility."

Here is the back cover of Mr Marx' book:

"We're going to hurt each other -- it's a fact of life, a cost of doing business. On the bright side, we can reduce the odds. We can design better systems, and we can make better choices. Along the way, we could quit suing each other, we could abandon our "no harm, no foul" approach to personal accountability, we could rewrite regulations and corporate policies that outlaw human error, and we could rethink how we respond to our children's mistakes.

Marx addresses regulators, attorneys, corporate CEOs, public policy makers, the media, and even parents to show that current social perspectives toward our inherent human fallibility have substantially hindered efforts to make the world a safer place to live. While his observations are primarily about American culture, the lessons are universal. Insightful, bold, and told through often humorous tales, Whack-a-Mole pushes readers to rethink what it means to be accountable -- at work, at home, and at play."

A must read for anyone in the Patient Safety arena... as Dr Lucian Leape testified to Congress -- the single greatest impediment to error prevention in the medical industry is that "we punish people for making mistakes."

AHRQ Patient Safety and Quality: An Evidence-Based Handbook for Nurses

2009-08-30T17:38:00.000-07:00

Wow!! I know it's been a while since I posted anything, but you're really got to check this handbook out!! This is a free - FREE - Patient Safety Handbook from the Agency for Healthcare Research and Quality (AHRQ). It's three volumes that includes five sections: Patient Safety and Quality, Evidence-Based Practice, Patient-Centered Care, Working Conditions and Environment, Clinical Opportunities for Improvement, and Tools for Improvement. You really have to go online and order a copy (www.ahrq.gov). It covers falls, pressure ulcers, emergency preparedness, handoffs, error reporting, medication administration, communication, workflow - and more! It even discusses the impact of facility design on patient safety. You can also request it on CD. Please go get a copy and check it out!

Understanding Patient Safety

2009-07-22T15:59:00.000-07:00

Understanding Patient Safety by Robert Wachter. The best part of this book is that the author actually added an entire section entitled "Solutions." Imagine that... there are ideas about improving your information technology system, the benefits of simulation, the role of the patient, a well trained, competent workforce, and a strong Patient Safety Manager. It's a lot of great information. Choose any one of them and design a plan to implement your favorite.

I like the idea of including the patient as a member of the healthcare team. There are all kinds of pamphlets available online to use as teaching material. Teach them the signs and symptoms of a post-operative infection, how to monitor staff for hand hygiene, or when to speak up if they have questions about their plan of care. It's simple and easy to implement. And the patients usually enjoy being such an integral part of the team.

Another great idea is Leadership Rounds. And it doesn't cost anything but time with your staff. Recruit your fellow leaders to join you at least once a month. Let the staff know that you are interested in how they think the program can be improved. "Is there anything that leadership can do to prevent the next adverse event?" "Are we actively promoting a blame-free culture of reporting?" The frontline workers are the most in tune with what works and what does not. Once they get used to seeing senior leaders walk through and ask questions, they will welcome the opportunity to participate and share their ideas.

What was your favorite solution?

Preventing Medication Errors

2009-07-07T15:27:00.000-07:00

Cover via Amazon

"Preventing Medication Errors" is another IOM report. You really have to read this book! I have earmarked more pages in this one than any other. Product labeling, packaging, free samples, inserts, overutilization, underutilization, access to knowledge bases, etc.

What can we do with all of this information? Well, you can collect ALOT of data and make some related process improvements. For instance, how many viral infections were diagnosed at your facility for which an antibiotic was prescribed? Overutilization... is there a CPT code you can track for viral diagnoses - check the database to see if an antibiotic was ordered? How much did the medication cost the facility? What would the savings be if it had not been ordered? Perhaps you can just track the clinic that prescribed the most antibiotics. Just a thought... savings always help rally in the troops when it comes to data.

What about underutilization? How many patients that presented with myocardial infarction received a beta-blocker? How about those diagnosed with a stroke - did they receive an anticoagulant? Osteoporosis - calcium supplement? You can collect some valuable metrics with the information in this book - improve patient outcome and improve the quality of care you provide.

Has anyone else read it?

Standardizing Medication Labels

2009-07-01T16:40:00.000-07:00

Image via Wikipedia

I heard on the news last night that acetaminophen is actually the leading cause of liver failure. Even low doses taken over time may have a cumulative effect and can cause liver damage. So it got me thinking about medication labeling... are we doing a good job informing our patients of their risks? Do our patients on opioid pain relievers take Tylenol as well?

Check out this Institute of Medicine workshop summary: "Standardizing Medication Labels; Confusing Patients Less." This book is a quick read - take it with on a long flight. What I like best about it is that is encourages simplification. "Take two pills every morning at 6a.m. and two pills at 6p.m." as opposed to "Take two tablets by mouth twice daily."

It's great if you and I read it as Patient Safety Managers. But what if the P&T Chairperson read it? What if the committee took 5 ideas from the book and incorporated it into the Annual Plan? Would it change your facility medication error metrics? Would it increase patient safety?

Why Hospitals Should Fly

2009-06-28T12:36:00.000-07:00

Cover via Amazon

This book won the James A. Hamilton 2009 American College of Healthcare Executives Book of the Year. The full title is "Why Hospitals Should Fly; the Ultimate Flight Plan to Patient Safety and Quality Care" by John J. Nance, JD. Mr Nance creates a fictional hospital of the future in which all staff members are empowered - and invited - to form the best treatment plans for their patients as a team. If you are familiar with the TeamStepps concept, you will see it used throughout the book. Staff members continuously "huddle" to discuss the latest plan of care, they brief prior to procedures, and debrief afterwards in an effort to enhance their next performance.

As we all know, the number one causative factor in reported sentinel events is communication. This book acknowledges that we still make too many assumptions in healthcare... we assume that the nurse is familiar with each post-op protocol, we assume that the doctor knowingly did not write an order, or that the pharmacist knows the doctor's handwriting and can tell what medication he wants for the patient. It's a great book related to communicating and teamwork.

Intro

2009-06-27T11:56:00.000-07:00

Hello! My name is Denise. I have been involved in the Patient Safety Program since 2002. I've held positions at both the hospital and corporate levels, attended numerous conferences, and read many related books and articles. This blog is an effort to bring people together that share a similar desire to enhance patient safety by reviewing past and current literature by the best and the brightest. In doing so, I hope to stimulate discussion to aid in the transition from band aid fixes to system level changes.

Internal Bleeding

2009-06-27T07:36:00.000-07:00

I would like to open the discussion with one of my favorite books by Robert Wachter, "Internal Bleeding." He is a strong advocate of the system level fix philosophy and his book is a "must read" for anyone that can envision a global dedication to patient safety. He reinforces the idea that telling the nurse or the doctor to change their behavior is not enough. We have to demand that manufacturers of medical equipment work with our patient safety advocate groups to ensure that fail safes are built into their programs. For example, during a recent Root Cause Analysis involving an infant in which both the nurse and the doctor calculated the dose incorrectly, the team realized that the medication dispensing machine could be designed to prevent dosing errors... if it had required that the patient's weight be entered with the selected medication, the machine could be programed to calculate the appropriate dose prior to dispensing. Normal infant weight ranges would be included to identify inappropriate entries. This is a system level fix. It doesn't require human perfection.

OK... I want you all to be able to share your thoughts about "Internal Bleeding" as well. Please let me know what you thought.