Understand the Science of Safety:

Presentation Slides

The Understand the Science of Safety module of the CUSP Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will provide a higher quality of patient-centered care on their hospital unit.

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Contents

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Slide 1: Cover Slide

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Image: CUSP Toolkit logo.

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Slide 2: Learning Objectives

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In this module, we will:

  1. Describe the historical and contemporary context of the Science of Safety
  2. Explain how system design affects system results
  3. List the principles of safe design and identify how they apply to technical work and teamwork
  4. Indicatel how teams make wise decisions when there is diverse and independent input

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Slide 3: Putting Safety in Context

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Advances in medicine have led to positive outcomes:

  • Most childhood cancers are curable
  • AIDS is now a chronic disease
  • Life expectancy has increased 10 years since the 1950s

However, sponges are still found inside patients’ bodies after operations.

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Slide 4: Health Care Defects

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In the U.S. health care system:

  • 7 percent of patients suffer a medication error.2
  • On average, every patient admitted to an intensive care unit suffers an adverse event.3, 4
  • 44,000 to 99,000 people die in hospitals each year as the result of medical errors.5
  • Over half a million patients develop catheter-associated urinary tract infections resulting in 13,000 deaths a year.6
  • Nearly 100,000 deaths from health care-associated infections (HAIs) each year and the cost of HAIs is $28 to $33 billion per year.7
  • Estimated 30,000 to 62,000 deaths from central line-associated blood stream infections per year.8

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Slide 5: How Can These Errors Happen?

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  • People are fallible.
  • Medicine is still treated as an art, not a science.
  • Systems do not catch mistakes before they reach the patient.

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Slide 6: The Science of Safety

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  • Every system is perfectly designed to achieve its end results.
  • Safe design principles must be applied to technical work and teamwork.
  • Teams make wise decisions when there is diverse and independent input.

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Slide 7: System-Level Factors Affect Safety9

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Image: Concentric circles show the layered system-level factors that affect patient safety: institutional factors, hospital factors, departmental factors, work environment factors, team factors, individual provider factors, and task factors all have an effect on patient safety.

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Slide 8: Safety is a Property of the System

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Slide 9: System-Level Factors Can Predict Performance

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Examples of the Impact of System-Level Factors

System FactorEffect
Daily rounds with an intensivistWhen ICUs are staffed with a multidisciplinary team, including daily rounds with an intensivist, mortality is reduced
Nurses responsible for more than two patientsWhen nurses are responsible for more than two patients, there is an increased risk of pulmonary complications in the ICU patient population
Point-of-care pharmacist or pharmacist who participates in roundsA point-of-care pharmacist or one who participates in rounds reduces prescribing errors

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Slide 10: Three Principles of Safe Design

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The three principles of safe design are standardize, create independent checks, and learn from defects.

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Slide 11: Standardize When You Can

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Slide 12: Create Independent Checks

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Slide 13: Learn From Defects

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Slide 14: Exercise

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Think about a recent safety issue in your unit and answer the four Learning from Defects questions:

  • What happened?
  • Why did it happen?
  • How will you reduce the risk of recurrence?
  • How will you know it worked?

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Slide 15: Principles of Safe Design Apply to Technical Work and Teamwork

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Slide 16: Technical Work and Teamwork

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Slide 17: Exercise

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How do you see technical and adaptive work fitting in your unit?

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Slide 18: Teams Make Wise Decisions When There is Diverse and Independent Input

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Slide 19: Exercise

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Appreciate the wisdom of crowds

  • Emphasize that health care is a team effort
  • Develop an environment where frontline providers can voice concerns, and are acknowledged when they express concerns
  • Gather as many viewpoints as possible
Alternate between convergent and divergent thinking
  • Divergent thinking occurs on rounds, during brainstorming sessions, and when trying to understand what might be occurring10
  • Convergent thinking occurs while formulating a treatment plan or focusing on a specific task10

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Slide 20: Basic Components and Process of Communication11

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Provider A – Sender and Receiver

  • Noise
  • A’s Context
  • Encoding and Decoding

Messages

  • Channel

Provider B – Sender and Receiver

  • Noise
  • B’s Context
  • Encoding and Decoding

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Slide 21: Diverse and Independent Input

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Slide 22: Reduced CRBSI By Applying Principles of Safe Design12

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Time PeriodMedian Catheter-Related Blood
Stream Infection (CRBSI) Rate
Incidence Rate Ratio
Baseline2.71
Pre-intervention1.60.76
0-3 months00.62
4-6 months00.56
7-9 months00.47
10-12 months00.42
13-15 months00.37
16-18 months00.34

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Slide 23: Understand the Science of Safety: What the Team Must Do

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  • Develop a plan so all staff on your unit view the Understand the Science of Safety video.
  • Video screening should be mandatory for all unit staff.
  • Create a list of who has watched the video.
  • Describe the three principles of safe design:
    1. Standardize.
    2. Create independent checks.
    3. Learn from defects.

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Slide 24: Summary

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  • Every system is designed to achieve its anticipated results.
  • The principles of safe design are standardize when you can, create independent checks, and learn from defects.
  • The principles of safe design apply to technical work and teamwork.
  • Teams make wise decisions when there is diverse input.

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Slide 25: CUSP Tools

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  • Daily Goals Checklist
  • Morning Briefing
  • Shadowing Another Professional Tool
  • Observing Patient Care Rounds
  • Team Check-Up Tool

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Slide 26: TeamSTEPPS Tools1

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  • Brief
  • Huddle
  • Debrief
  • SBAR
  • Check Back
  • Call Out
  • Hand Off
  • I PASS the BATON
  • DESC Script

*Please refer to the “Implement Teamwork and Communication” module for additional information*

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Slide 27: References

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1.Agency for Healthcare Research and Quality, Department of Defense. TeamSTEPPS. Available at http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html
2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29-34.
3. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300.
4. Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 349:309-313,1997.

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Slide 28: References

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5. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
6. Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March 2009. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf (Plugin Software Help)
7. Klevens M, Edwards J, Richards C, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR. 2007;122:160-166.
8. Ending health care-associated infections, AHRQ, Rockville, MD, 2009. http://www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/.
9. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–57.

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Slide 29: References

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10. Heifetz R. Leadership without easy answers, president and fellows of Harvard College. Cambridge, MA: Harvard University Press;1994.
11. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007;33(1): 34-47.
12. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32.

Current as of December 2012
Internet Citation: Understand the Science of Safety:: Presentation Slides. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetyslides.html