Identify Defects Module Alternate Text

Slide Number and TitleSlide ContentContent for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)The "Identify Defects Through Sensemaking" module of the Comprehensive Unit-Based Safety Program (CUSP) Toolkit. The CUSP Toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected and are aimed at improving patient safety.
Slide 2
CUSP and Sensemaking Tools
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
Tools icon
Slide 3
Learning Objectives
  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
 
Slide 4
The Relationship Between CUSP and Sensemaking1,2,3
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

CUSP and Sensemaking use different terms to identify defects or errors. CUSP uses the term "defect" while Sensemaking uses the term "failure" and further classifies failures as (1) human/active failure or (2): latent/system conditions. 

CUSP uses the Staff Safety Assessment and Status of Safety Issues Worksheet to identify defects. Sensemaking uses the Discovery Form, Root Cause Analysis, Failure Mode and Effects Analysis, and Probabilistic Risk Assessment tools to identity failures. 

CUSP uses the Learn From Defects Form to examine defects while Sensemaking uses the Causal Tree Worksheet to examine failures. 

CUSP uses the Learn From Defects Form to code defects, while Sensemaking uses the Eindhoven Model to code failures.

Slide 5
Identify Defects and Use Sensemaking
  
Slide 6
Identify Defects Overview
  • Define defects
  • Identify sources of defects
  • Apply CUSP tools to identify defects
 
Slide 7
Sensemaking Overview4
  • 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
 
Slide 8
Examples of Defects or Errors That Affect Patient Safety
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
The table presents a series of defects and their interventions:
  1. Unstable oxygen tanks on beds resulted in an intervention in which oxygen tank holders were repaired or new holders were installed across the institution.
  2. A medication look-alike incident led to an intervention in which education was conducted, medications were physically. Separated, and letters were sent to the manufacturer.
  3. Missing equipment on a cart resulted in the development of a checklist for stocking the cart.
  4. The inconsistent use of Daily Goals rounding tool resulted in a group consensus on required elements of the Daily Goals rounding tools.
  5. Inaccurate information by residents during rounds resulted in the development of an electronic progress note.
Slide 9
Reason's Swiss Cheese Model5
 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."
Slide 10
CUSP Tools to Identify Defects
  
Slide 11
Staff Safety Assessment
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?
Image of the Staff Safety Assessment Form with three arrows pointing at it. The top arrow contains the text: What are clinical or operational problems that have or could have jeopardized patient safety? The middle arrow contains the text: How might the next patient be harmed in our unit? The bottom arrow contains the text: What can be done to minimize harm or prevent safety hazards?.
Slide 12
Exercise
Please complete the following:
  • List all defects that have the potential to cause harm
  • Discuss the three greatest risks
  • Rank these risk factors
Exercise icon
Slide 13
Use the Safety Issues Worksheet for Senior Executive Partnership
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.
Image of Safety Issues Worksheet for Senior Executive Partnership with three arrows pointing at it. The top arrow contains the text: Step 1. Engage the senior executive in addressing the safety issues identified on the form. The middle arrow contains the text: Step 2. Use the form during safety rounds to identify safety issues, identify potential solutions, and identify resources. The bottom arrow contains the text: Keep the project leader apprised of the information on this form.
Slide 14
Sensemaking Tool to Identify Defects: Root Cause Analysis
  
Slide 15
Root Cause Analysis: Causal Tree Worksheet5
  • Discovery Event
  • Antecedent Event
  • Root Causes
  • Root Cause Classification Codes
  • Recovery
The causal tree is made up of five rows. At the top of the tree and at the top row is where the discovery event would go. The discovery event addresses what happened. The next two rows are labeled antecedent events and would contain the answers to a series of "whys" to help understand the root causes of the event, which would go in the next row on the tree. The last row would contain the root cause classification codes, which will be discussed later in this presentation. The left side of the tree is labeled the failure side, and a small part of the right side is labeled the recovery side. The recovery side is only completed if something prevented the event from reaching the patient.
Slide 16
Root Cause Analysis Example5
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
A Causal Tree shows that the discovery event is a Group O patient almost given Group A blood. Recovery occurred when a nurse interrupting the transfusion because the nurse noticed that the unit was A positive As part of the root cause analysis, the following antecedent events are identified:
  1. An A positive unit was hanging from the infuser and the A positive unit was not removed after the previous case.
  2. The transfusing nurse didn’t check the blood type on the hanging unit because the nurse was busy and distracted.
The root causes were identified as:
  1. The temp nurse was unclear about the procedure.
  2. The temp nurses needed help.
  3. Other nurses were on sick-out.
Slide 17
Learning From Defects and Sensemaking
  
Slide 18
Learning From Defects Overview
  • 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
 
Slide 19
Exercise
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?
Exercise Icon
Slide 20
CUSP Tools to Learn From Defects
  
Slide 21
Learning From Defects: Four Questions
  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?
Each question is in a box, and the boxes are stacked. An arrow leads down from the bottom of each of the first three boxes to the top of the next box, showing how one question leads to the next.
Slide 22
What Happened?
(vignette still)
Click to play
Video icon
Slide 23
Why Did It Happen?
(vignette still)
Click to play
Video icon
Slide 24
What Will You Do to Reduce the Risk of Recurrence?
(vignette still)
Click to play
Video icon
Slide 25
How Will You Know the Risk is Reduced?
(vignette still)
Click to play
Video icon
Slide 26
Sensemaking Tools to Learn From Defects
  
Slide 27
Causal Coding: Eindhoven Model5
  • 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
 
Slide 28
Root Cause Analysis Example6
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
There are three root causes and root cause classification codes. The first root cause reads: "Temp nurse unclear about procedure," and the classification code is "OK" (Organizational, Knowledge transfer—because the temp nurse was not fully briefed on the hospital's procedures at the start of her shift ) The second root cause reads: "Nurse was busy and distracted," and the classification code is "OM" (Organizational, Management— many regular nurses were on sick-out, due to management's decision to decrease vacation benefits). The third root cause reads: "Nurse sees that unit is A positive," and the classification code is "HEX" (Human, External to the organization— the temps needed help because they were from outside the agency).
Slide 29
CUSP and Sensemaking: Next Steps
  
Slide 30
Summarize and Share Your Findings
  • 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)
 
Slide 31
Communicating the Learning
  • 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
 
Slide 32
Summary: Sensemaking and Identifying Defects
  • 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
 
Slide 33
Summary of Sensemaking and Learning From Defects
  • 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
 
Slide 34
References
  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.
 
Slide 35
References
  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.
 
Page last reviewed March 2013
Internet Citation: Identify Defects Module Alternate Text. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/identify/identifyalttext.html