Identify Defects Through Sensemaking

CUSP Toolkit

The Identify Defects Through Sensemaking module of the CUSP Toolkit will help you identify recurring negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm to your patients.

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Contents

Slide 1. Cover Slide
Slide 2. CUSP and Sensemaking Tools1
Slide 3. Learning Objectives
Slide 4. The Relationship Between CUSP and Sensemaking1,2,3
Slide 5. Identify Defects and Use Sensemaking
Slide 6. Identify Defects Overview
Slide 7. Sensemaking Overview4
Slide 8. Examples of Defects or Failures That Affect Patient Safety
Slide 9. Reason’s Swiss Cheese Model5
Slide 10. CUSP Tools To Identify Defects
Slide 11. Staff Safety Assessment
Slide 12. Exercise
Slide 13. Use the Safety Issues Worksheet for Senior Executive Partnership
Slide 14. Sensemaking Tool To Identify Defects: Root Cause Analysis
Slide 15. Root Cause Analysis: Causal Tree Worksheet6
Slide 16. Root Cause Analysis Example6
Slide 17. Learning From Defects and Sensemaking
Slide 18. Learning From Defects Overview
Slide 19. Exercise
Slide 20. CUSP Tools To Learn From Defects
Slide 21. Learning From Defects: Four Questions
Slide 22. What Happened?
Slide 23. Why Did It Happen?
Slide 24. What Will You Do To Reduce the Risk of Recurrence?
Slide 25. How Will You Know the Risk Is Reduced?
Slide 26. Sensemaking Tools To Learn From Defects
Slide 27. Causal Coding: Eindhoven Model6
Slide 28. Root Cause Analysis Example6
Slide 29. CUSP and Sensemaking: Next Steps
Slide 30. Summarize and Share Findings
Slide 31. Communicating the Learning
Slide 32. Summary: Sensemaking and Identifying Defects
Slide 33. Summary of Sensemaking and Learning From Defects
Slide 34. References
Slide 35. References


 

Slide 1: Cover Slide

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(CUSP Toolkit logo)

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Slide 2: CUSP and Sensemaking Tools1

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CUSP Tools

  • Staff Safety Assessment
  • Safety Issues Worksheet
  • Learn from Defects Form

Sensemaking Tools

  • Discovery Form
  • Root Cause Analysis
  • Failure Mode and Effects Analysis
  • Probabilistic Risk Assessment
  • Causal Tree Worksheet

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Slide 3: Learning Objectives

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  1. Introduce CUSP and Sensemaking tools to identify defects or conditions
  2. Discuss the relationship between CUSP and Sensemaking
  3. Show how to apply CUSP and Sensemaking tools
  4. Discuss how to share findings

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Slide 4: The Relationship Between CUSP and Sensemaking1,2,3

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ConceptCUSPSensemaking
Defect or failure identificationDefects
  1. Human/active failure
  2. Latent/system conditions
Ways to identify defects or failure
  • Staff Safety Assessment
  • Status of Safety Issues Worksheet
  • Discovery Form
  • Root Cause Analysis
  • Failure Mode and Effects Analysis
  • Probabilistic Risk Assessment
Tools to examine defects or errorsLearn from Defects FormCausal Tree Worksheet
Coding defects or errorsLearn From Defects FormEindhoven Model

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Slide 5: Identify Defects and Use Sensemaking

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Slide 6: Identify Defects Overview

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  • Define defects.
  • Identify sources of defects.
  • Apply CUSP tools to identify defects.

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Slide 7: Sensemaking Overview4

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  • A conversation among members of an organization involved in an event/issue.
  • The purpose is to reduce the ambiguity about the event/issue—literally to make sense of it.
  • Each person brings his or her experience of that event/issue to the discussion.
  • The conversation is the mechanism that combines that knowledge into a new, more understandable form for the members.
  • Members develop a similar representation in their minds that allows for action that can be implemented and understood by all who have participated in the conversation.

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Slide 8: Examples of Defects or Failures That Affect Patient Safety

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DefectIntervention
Unstable oxygen tanks on bedsOxygen tank holders repaired or new holders installed institution wide
Medication look-alikeEducation conducted, medications physically separated, and letter sent to manufacturer
Missing equipment on cartChecklist developed for stocking cart
Inconsistent use of Daily Goals rounding toolConsensus reached on required elements of Daily Goals rounding tool
Inaccurate information by residents during roundsElectronic progress note developed

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Slide 9: Reason’s Swiss Cheese Model5

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Image: Four slices of Swiss cheese with an arrow passing through the aligned holes. The blunt end of the arrow is labeled “Hazards,” and the sharp end is labeled “Losses.”

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Slide 10: CUSP Tools To Identify Defects

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Slide 11: Staff Safety Assessment

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Step 1: What are clinical or operational problems that have or could have jeopardized patient safety?
Step 2: How might the next patient be harmed in our unit?
Step 3: What can be done to minimize harm or prevent safety hazards?

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Slide 12: Exercise

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Please complete the following:

  • List all defects that have the potential to cause harm.
  • Discuss the three greatest risks.
  • Rank these risk factors.

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Slide 13: Use the Safety Issues Worksheet for Senior Executive Partnership

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Step 1. Engage the senior executive in addressing the safety issues identified on the form.
Step 2. Use the form during safety rounds to identify safety issues, identify potential solutions, and identify resources.
Step 3. Keep the project leader apprised of the information on this form.

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Slide 14: Sensemaking Tool To Identify Defects: Root Cause Analysis

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Slide 15: Root Cause Analysis: Causal Tree Worksheet6

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  • Discovery Event
  • Antecedent Event
  • Root Causes
  • Root Cause Classification Codes
  • Recovery

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Slide 16: Root Cause Analysis Example6

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Discovery Event

  • Group O patient almost given Group A blood.

Antecedent Events

  • A positive unit was hanging on the infuser.
    • A positive unit not removed prior to case.
  • Transfusing nurse didn’t check blood type on hanging unit.
    • Nurse was busy and distracted.

Recovery

  • Nurse interrupts transfusion.
  • Nurse sees that unit is A positive.

Root Causes

  • Temp nurse unclear about procedure.
  • Temp nurses need help.
  • Other nurses on sick-out.

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Slide 17: Learning From Defects and Sensemaking

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Slide 18: Learning From Defects Overview

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  • Health care providers are adept at reacting to an event and finding a solution.
  • Providers must also correct the factors that contribute to an event.

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Slide 19: Exercise

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Think of an unexpected situation that you recently encountered:

  • When did you know it was not what you expected
  • What were the clues?
  • What sense did you make of it?

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Slide 20: CUSP Tools To Learn From Defects

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Slide 21: Learning From Defects: Four Questions

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  1. What happened?
  2. Why did it happen?
  3. What will you do to reduce the risk of recurrence?
  4. How will you know the risk is reduced?

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Slide 22: What Happened?

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Slide 23: Why Did It Happen?

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Slide 24: What Will You Do To Reduce the Risk of Recurrence?

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Slide 25: How Will You Know the Risk Is Reduced?

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Slide 26: Sensemaking Tools To Learn From Defects

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Slide 27: Causal Coding: Eindhoven Model6

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  • 20 separate event cause types in four categories:
    1. Technical
    2. Organizational
    3. Human
    4. Other
  • Aim for three to seven root cause codes for each event, a mixture of active and latent.
  • All events involve multiple causes.

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Slide 28: Root Cause Analysis Example6

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Root causes

  • Temp nurse unclear about procedure.
  • Transfusing nurse busy and distracted.
  • Both nurses from outside the agency.

Root Cause Classification Codes

  • OK
  • OM
  • HEX

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Slide 29: CUSP and Sensemaking: Next Steps

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Slide 30: Summarize and Share Findings

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  • Create a one-page summary answering the four Learning from Defects questions.
  • Share the summary within your organization.
    • Engage staff in face-to-face conversations to provide opportunities to learn from defects.
  • Share de-identified information with others in your state collaborative (pending institutional approval).

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Slide 31: Communicating the Learning

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  • Team meetings—monthly.
  • Meeting to review data—monthly.
  • Meeting with executive partner—monthly or more often.
  • Executive review of data—monthly.
  • Presentations to hospital colleagues as needed, including leadership, frontline staff, and board.

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Slide 32: Summary: Sensemaking and Identifying Defects

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  • Identify defects and Sensemaking share several common themes.
  • Defects or failures are clinical or operational events that you do not want to happen again.
  • CUSP and Sensemaking tools help teams identify defects and identify ways to deter them from occurring in the future.

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Slide 33: Summary of Sensemaking and Learning From Defects

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  • Sensemaking and Learning from Defects share several common themes.
  • The Learning from Defects tool can be used to facilitate a sensemaking conversation.
  • The Causal Tree Worksheet and Eindhoven Model can help identify and target defects in your unit.
  • Sensemaking and Learning from Defects are ongoing processes.

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Slide 34: References

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  1. Battles JB, Kaplan HS, Tjerk W Van der Schaaf, et al. The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med 1998 March;122:231-238.
  2. Battles JB, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Hlth Svcs Res 2006;41(Aug 4 Pt 2.):1555-1575.
  3. Sensemaking. Patient safety analysis training. http://dkv.columbia.edu/demo/medical_errors_reporting/site/module1/index.html. Accessed August 18, 2011.

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Slide 35: References

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  1. Sensemaking. Patient safety analysis training. http://dkv.columbia.edu/demo/medical_errors_reporting/site/ module3/index.html. Accessed August 18, 2011.
  2. Pronovost PJ, Wu AW, and Sexton JB. Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit. Ann Intern Med 2004 June;140(12):1025-1033.
  3. Sensemaking. Patient safety analysis training. http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/0100-module-outline.html. Accessed August 29, 2011.
Current as of December 2012
Internet Citation: Identify Defects Through Sensemaking: CUSP Toolkit. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/identify/identify.html