TOPICS IN PATIENT SAFETY®

VOL. 12, ISSUE 2 March/April 2012

Contents Summary of fourth national patient safety survey Pages 1 and 4: Summary By Joe Murphy, APR, NCPS public affairs officer of fourth national patient safety survey NCPS conducts a VHA-wide patient safety She has provided numerous patient survey every three to five years to assess managers detailed information on specific facility Page 2: patient safety culture. Four national surveys have results. “They have consistently asked, ‘How can Avoiding a single point been conducted since 2000, the latest occurring in we better address whatever problems we find?’ ” of failure: Fault tolerance 2011, with more than 48,000 participants (Table 1). Ignaczak noted. and patient safety An important result from each survey is that Some of the issues can be resolved through Page 3: NCPS can provide facilities with an individual- implementing NCPS programs, such as Medical Getting “SERIOUS” ized data analysis, permitting them to drill down Team Training and Clinical Crew Resource Man- about medication into various occupation groups (Table 2). This agement, which foster improved teamwork and reconciliation allows for the identification of occupation groups communication. that contribute most significantly to the perception “But we also like to get ideas from the field of patient safety at their facility. Facility results as to what they are doing to address issues at their VA National for each occupation group can also be compared facilities,” she said. “When drilling down to the Center for to the network and national results for that group. different occupational groups in the survey, I tell Patient Safety A new analysis tool developed by NCPS people that while you want to look at those groups P.O. Box 486 Ann Arbor, MI 48106-0486 identifies facilities with high and low perceptions that have lower than the VHA average, you also of the patient safety culture. want to take a look at are higher than the VHA Phone:...... (734) 930-5890 Culture change can be recognized when staff average.” Fax:...... (734) 930-5877 members understand and perform what is required Individuals in the latter group may be con- E-mail:...... [email protected] to create a safe patient experience at their facili- ducting business in such a way that can serve as a Web Sites: ties, which is measured in the survey using 14 model to others. “What are they doing better? Can ...... www.patientsafety.gov specific dimensions (Table 3), such as “Teamwork the lessons learned be disseminated to the rest of Robin R. Hemphill, M.D., M.P.H. Within Hospital Units” and “Frequency of Event the facility? Are there best practices that can ben- Deputy Chief Patient Safety Officer Reporting.” efit all, rather than just a single group?” Ignaczak Director, VA National Center continued. for Patient Safety Comparing the surveys Editor Benchmarks Joe Murphy, M.S., APR Aartee Ignaczak, the NCPS program analyst Public Affairs Officer who managed the 2011 survey, said few major Five dimensions of the VHA-wide survey are Graphic Design and Copy Editing changes were seen at the national level, further comparable to the Agency for Healthcare Re- Deborah Royal noting that the most important comparisons are search and Quality (AHRQ) patient safety surveys Visual Information Specialist made at the facility and network levels. for public and private hospitals. TIPS is published bimonthly “The average responses at the national level Results from past AHRQ comparisons have by the VA National Center for didn’t go significantly up or down across the shown an overall favorable comparison between Patient Safety. As the official board,” she said, “and that is a positive sign.” VHA and the AHRQ benchmarks, such as VHA patient safety newsletter of the One of the 14 dimensions of the survey, “non- Department of Veterans Affairs, it scoring 80 percent to 70 percent in organizational is meant to be a source of punitive response to error,” has shown a slight learning in 2009. patient safety information for decline across all four surveys. “The frequency of event reporting at other all VA employees. Opinions of “We want the trends of the averages to be organizations is somewhat higher in the latest contributors are not necessarily increasing. So I think it is a challenge, then, to survey,” she said, “but not significantly so.” those of the VA. Suggestions and determine underlying causes and ways to improve articles are always welcome. Ignaczak noted that such comparisons with this perception of patient safety,” Ignaczak said. outside organizations are important, as they pro- Thanks to all contributors and “If there is the pervasive culture at a facility or those NCPS program managers vide a needed prospective on VHA’s patient safety and analysts who offered their work unit where people believe they are going to efforts (Table 4). time and effort to review and be punished for reporting an error, or making an “We will always be looking for new ideas that comment on these TIPS articles error, then it is much less likely an error will be will allow us to improve future national results,” prior to publication. reported and the system improved.” she said, “and the key to doing this is to continue Patient safety managers, however, are con- to partner with patient safety managers at the tinually looking for ways to advance programs at facility level.” their facilities. Continued on page 4 Avoiding a single point of failure: Fault tolerance and patient safety By Joe Murphy, APR, NCPS public affairs officer

NCPS programs focus on the reduc- • Graphically describe the process be- • Failure can occur if the identification tion and prevention of inadvertent harm ing studied. Team members develop relies on a single point in the system; to patients as a result of their care, using and verify a flow process diagram. communication is vital, i.e., “speaking a number of tenets adapted from fault- Each step in the process under study up” if an error is noticed tolerance design principles. is identified and numbered. If a • The “expense” of system failure Background process is complex, a specific area is would be felt by the patient – as a identified to keep the effort manage- potential adverse event – and by its We take a systems approach to prob- able. Appropriate sub-processes result on efficiency and effectiveness lem solving, focused on prevention, not are also identified and flow process in the operating room punishment. In most cases, a chain of events that diagrams developed. Backup components has gone unnoticed leads to a recurring Another step in the HFMEA process Fault-tolerant designs can also safety problem. It is seldom related to the focuses on “fault containment to prevent mitigate or limit of the effects of errors actions of just one individual. propagation of the failure”: after they have been made, by includ- A successful approach to improving • Conduct a analysis. Focusing ing “backup components” that “kick in,” patient care must therefore include looking should one component fail.3 for ways to break that link in the chain of on the sub-processes, team members list all potential failure modes to de- In one final example, compare this to events that can cause a recurring problem one aspect of The Daily Plan®, an NCPS – which can lead one to consider building termine their severity and probability. Cognitive aids developed by NCPS initiative that enhances patient safety by care systems that are fault-tolerant. involving patients in their care.2 Such systems can reduce or eliminate to support teams at this step include a Scoring Matrix and a Decision Tree. A single document is provided to the possibility that harm can come to a pa- them that outlines what can be expected tient, because these systems are designed to The Scoring Matrix is used to deter- on a specific day of hospitalization. succeed even if individual components fail. mine the probability of an event’s reoccur- In this case, imagine a nurse using The fault-tolerance principle has been rence and severity; the Decision Tree to the document as the basis for a discus- used for years by the aviation industry and determine if corrective actions should sion with a patient concerning upcoming other high-reliability industries. be taken. events that day. The patient notices a test Basic characteristics An HFMEA team’s final step is to de- is missing, one that a physician had told the patient was scheduled occur. The basic characteristics of fault termine what best course of action to take. The error was thus not only mitigated, tolerance in industry require: In an effort to avoid “a single point of failure,” outcome measures are identified but avoided, by including the patient as a • No single point of failure to analyze and test redesigned processes. “backup component.” • Fault isolation to the failing compo- In fact, during the 2009 “Phase 2” of nent; i.e., how easy is it to discover or Critical components The Daily Plan® pilot program, evalua- detect? Providing a fault-tolerant design for tions were completed by 198 hospitalized • Fault containment to prevent propaga- every component in a system is normally patients and 85 nurses: tion of the failure; i.e., how easy is it not an option. • 47.5 percent of the patients reported to recover? When thinking of examples in other that either they or their family mem- industries, the following criteria are used • Availability of “reversion modes”; ber found and asked about a discrep- 1 to determine which components – each i.e., ancy in their planned care playing a specific part of a chain of events Healthcare Failure Mode Effect – should be fault-tolerant: Conclusion Analysis (HFMEA) is based on a five-step process used by interdisciplinary teams to • How critical is the component? Integrating fault-tolerance principles proactively evaluate a health care process, • How likely is the component to fail? into NCPS initiatives and programs has in an effort to create a fault-tolerant care • How expensive is it to make the com- been successful – and can be a signifi- 3 system.2 ponent fault-tolerant? cant tool in reducing inadvertent harm to patients as a result of their care. Specifically designed for health care Consider these criteria in relation professionals, the process offers analytical to the Medical Team Training program,2 Notes which emphasizes communication and tools that enable users to identify vulner- 1. Answers.com. Retrieved January 10, teamwork through -driven brief- abilities and deal with them effectively. 2012 from http://www.answers.com/ ings and debriefings. To illustrate how the HFMEA process topic/fault-tolerant-system relates to development of a fault-tolerant For instance, a preoperative briefing plays a specific role in the chain of events 2. Learn more about NCPS programs: care system, consider two of the steps http://www.patietsafety.gov used. This step focuses directly on “fault leading to an operation: • Used (in part) to correctly identify the 3. Wikipedia. Retrieved January 10, isolation to the failing component”: 2012 from http://en.wikipedia.org/ patient; a critical component wiki/Fault-tolerant_design Page 2 Getting “SERIOUS” about medication reconciliation An interdisciplinary medication reconciliation clinic wins Cheers Award By Joe Murphy, APR, NCPS public affairs officer

The departments of pharmacy and A multidisciplinary model, SERI- “But what if the patient is a dia- cardiology at the Louis Stokes Cleveland OUS shifts the focus of medication rec- betic and should be on a daily aspirin for VA Medical Center have been designated onciliation from the accuracy of a list to stroke prevention?” she continued, “that as a 2011 Cheers Award winner by the the needs of a patient, addressing quality is a ‘quality’ issue, not a safety issue. Institute for Safe Medication Practices. as well as safety. The SERIOUS model takes the National Staff members have continued to “Just because the medication list is Patient Safety Goal for overall safe care implement an innovative medication accurate, doesn’t mean that it is good,” a step further to improve patient-specific reconciliation model, known as “SERI- said Dr. Hoover. “Patients could accurate- care.” OUS,” which was created in 2008 by ly tell you that they do not take a daily One key further step, taken by phar- NCPS Patient Safety Physician Danielle aspirin – and there could be no aspirin on macists, was to review patient dosing reg- Hoover, M.D., M.P.H. the medication list in the chart; therefore, imens with cardiology staff to “optimize” “When I heard the clinic had won you would have met the National Patient them to guideline-recommended dosages, the award I was floored. I didn’t even Safety Goal of accurately reconciling when appropriate. By doing this, a suc- know it had been nominated! I did a medications.” cessful partnership has been developed Facebook status post that night, compar- between cardiology and pharmacy – and ing it to winning a ‘health has shown a decrease in 30- care Grammy,’ ” she said. day readmission rates. Dr. Hoover developed the “Facility leadership was impressed with the savings model when she served on the from decreased readmissions facility staff as a VA National and patients were excited to Quality Scholar and NCPS finally understand what they Patient Safety Fellow. were taking and why!” noted It incorporates all the Dr. Hoover. “We had patients Elements of Performance of who would bring rolling a then-proposed 2009 Joint suitcases full of pill bottles Commission National Patient with them. They were so Safety Goal, which focused appreciative of the time we on creating an accurate medi- took to educate them about cation list. their medications.” The SERIOUS model im- “Modern health care proves the medication recon- is moving to implement ciliation process by breaking standards that can be applied it down into small steps that consistently to each patient, can be performed by differ- while at the same time mov- ent members of a health care ing to more a patient-specif- team. ic, individualized medicine. Dr. Hoover partnered Although the model fits these with a team working to principles, my goal was prevent heart failure readmis- simply to change the process sions at the Cleveland VA of medication reconciliation from something you do to Medical Center. The model comply with a mandate, back was piloted at the team’s to something you do because post-discharge clinic, staffed it is right for the patient,” she by pharmacists and nurse concluded. practitioners. VA employees can find “I am really proud that more information about this my colleagues chose to con- clinic and the VA National tinue using the model over the Medication Reconciliation years and have integrated it Initiative at VA site. into how medication reconcil- iation is done at their facility,” she said.

Page 3 Summary of fourth national patient safety survey Continued from page 1 Note Patient safety managers and officers can contact Aartee Ignaczak via email to obtain a data CD that will allow them to “drill down” by organizational unit at their facilities: [email protected]

Table 1 The cross-hatched line in Dimensions 3 indicates a significantly higher average re- Table 2 sponse than the previous period; the cross-hatched lines in Dimensions 5 and 11 indicate a significantly lower average response than the previous period.

Table 3 Table 4 The cross-hatched lines for VHA for Dimensions 6 and 7 indicate significantly fewer positive responses than AHRQ.

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