1999 Institute of Medicine (IOM) report:
To Err is Human
Agency for Healthcare Research and Quality (AHRQ)
launched initiatives focused on safety
... [Show More] research for patients
2002 Joint Commission National Patient Safety Goals
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Key Features of a Safety Culture
Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
Organizational commitment of resources to address safety concerns (AHRQ, 2012, para. 1)
Failure Modes and Effect Analysis
is a systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change
Just Culture
Blame-free environment to encourage error reporting
System or process issues that lead to unsafe behaviors and errors are addressed by changing practices or workflows/processes.
Clear message is communicated that reckless behaviors are not tolerated.
Just Culture Error Types
Human error (unintentional mistakes)
Perform FMEA to understand error
Risky behaviors (workarounds or cutting corners)
Examine workflow; educate
Reckless behavior (total disregard for established policies and procedures)
Enact zero-tolerance policy; disciplinary measures
Promoting a Safety Culture
AHRQ suggests that teamwork training, executive walk-arounds, and unit-based safety teams have improved safety culture perceptions, but have not demonstrated a significant reduction in error rates.
IHI strategies include appointing a safety champion for every unit, creating an adverse event response team, and reenacting or simulating adverse events to better understand the organizational or procedural processes that failed.
Human Factors Engineering
The discipline of applying what is known about human capabilities and limitations to the design of products, processes, systems, and work environments. Its application to system design improves "ease of use, system performance and reliability, and user satisfaction, while reducing operational errors, operator stress, training requirements, user fatigue, and product liability
Alarm Fatigue
Medical equipment alarms frequently and inappropriately
May be related to the sensitivity of alarm parameters
Strategies to improve alarm response
Improve the patient call system by adding voice over Internet protocol (VOIP) phones
Feed alarm data into a reporting database for further analysis
Encourage healthcare professionals to round with physicians to provide input into alarm parameters
Informatics Technologies and Safety
Improve communication.
Reduce errors and adverse events.
Increase the rapidity of response to adverse events.
Make knowledge more accessible to clinicians.
Assist with decisions; Technology-based forcing functions that direct or restrict actions or orders implemented by computer technologies
Provide feedback on performance.
Most Frequent Safety Issues
The National Patient Safety Foundation (NPSF) top patient safety issues (2013):
Wrong site surgery
Hospital acquired infections
Falls
Hospital readmissions
Diagnostic error
Medication errors
Many of these issues can be prevented or early detected using informatics technologies.
Medication Administration Cycle
Assessing need
Ordering
Dispensing
Distributing
Administering
Evaluating
Human error factors: Distractions, unclear thinking, lack of knowledge, short staffing, and fatigue
Five Rights of Medication Administration
1.The right patient
2.The right time and frequency of administration
3.The right dose
4.The right route
5.The right drug
Technology Integration into Cycle
Reduces the potential for human errors by
Performing electronic checks
Providing alerts to draw attention to potential errors
Tracks performance
Computerized Physician Order Entry (CPOE) Benefits
Prompts warn against the possibility of drug interaction, allergy, or overdose.
Accurate, current information that helps physicians keep up with new drugs as they are introduced into the market
Drug-specific information that eliminates confusion among drug names that sound alike
Improved communication between physicians and pharmacists
Reduced healthcare costs due to improved efficiencies (LeapFrog Group, 2008)
Technology in the Pharmacy
Verifying function is computer based; the medication order is electronically checked via the knowledge database
Allergy verification and medication reconciliation with other drugs already in use
Barcode medication labeling or RFID technology
Assists with dispensing and administration
Automated dispensing machines
Storage, dispensing, controlling, and tracking
Barcode Medication Administration (BCMA)
Provides a system of checks and balances to ensure medication safety
Nurse scans name badge, thus logging in as the person responsible for medication administration.
Barcode on the patient's ID bracelet is scanned prompting the electronic system to pull up the medication orders.
Barcode on each of the medications to be administered is scanned.
This technology checks to ensure that the five rights of medication administration—right patient, right med, right dose, right route, and right time—are met. [Show Less]