Understand the Science of Safety Module Alternate Text

Slide Number and TitleSlide ContentContent for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)The "Understand the Science of Safety" module of the 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
Learning Objectives
  • Describe the historical and contemporary context of the Science of Safety
  • Explain how system design affects system results
  • List the principles of safe design and identify how they apply to technical work and teamwork
  • Indicate how teams make wise decisions when there is diverse and independent input
  • Describe the historical and contemporary context of the Science of Safety
  • Explain how system design affects system results
  • List the principles of safe design and identify how they  apply to technical work and teamwork
  • Indicate how teams make wise decisions when there is diverse and independent input
Slide 3
Putting Safety in Context
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.

Team members examining a patient’s X-ray.
Slide 4
Health Care Defects
In the U.S. health care system:
  • 7 percent of patients suffer a medication error2
  • On average, every patient admitted to an intensive care unit suffers an adverse event3,4
  • 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 year6
  • Nearly 100,000 deaths from health care-associated infections (HAIs) each year and the cost of HAIs is $28 to $33 billion per year7
  • Estimated 30,000 to 62,000 deaths from central line-associated blood stream infections per year8
 
Slide 5
How Can These Errors Happen?
  • People are fallible
  • Medicine is still treated as an art, not a science
  • Systems do not catch mistakes before they reach the patient
A sign indicating a wet floor is removed while the floor is still wet. As a result, a patient slips on the floor. 
Slide 6
The Science of Safety
  • 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
A group of team members conferring.
Slide 7
System-Level Factors Affect Safety9
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.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.
Slide 8
Safety is a Property of the System
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Click to play 
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Slide 9
System-Level Factors Can Predict Performance
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
Outcomes gained from small system factors can result in a monumental impact on safety performance. Having an intensivist on daily ICU rounds with a multidisciplinary team can reduce patient mortality. Having a nurse responsible for more than two patients in the ICU can increase the patient populations’ risk of pulmonary complications. Having a point-of-care pharmacist or a pharmacist who participates in rounds can help reduce prescribing errors.
Slide 10
Three Principles of Safe Design
Three principles of safe design are standardize, create independent checks, and learn from defects.Three principles of safe design are standardize, create independent checks, and learn from defects.
Slide 11
Standardize When You Can
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Slide 12
Create Independent Checks
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Click to play 
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Slide 13
Learn From Defects
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Click to play
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Slide 14
Exercise
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?
Exercise icon
Slide 15
Principles of Safe Design Apply to Technical Work and Teamwork
 Team members next to a line cart.
Slide 16
Technical Work and Teamwork
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Click to play
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Principles of Safe Design Apply to Technical and Teamwork [will insert alt text to PowerPoint once video is inserted]
Slide 17
Exercise
How do you see technical and adaptive work fitting in your unit?Exercise icon
Slide 18
Teams Make Wise Decisions When There is Diverse and Independent Input
 A health care team
Slide 19
How To Ensure Diverse and Independent Input
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
 
Slide 20
Basic Components and
Process of Communication11
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
Graphic description of the basic components and process of communication. The communication that takes place between two people is exposed to many roadblocks in between its transmission from one individual to another. First, the sender encodes, or creates, the message, which is influenced by the sender’s context, and then transmits the message to the receiver, who then must decode, or process, the message, based on the receiver’s context. While the message is being transmitted, it is exposed to noise interference that affects the context and clarity of the message that is sent and received.
Slide 21
Diverse and Independent Input
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Click to play 
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Slide 22
Reduced CRBSI By Applying
Principles of Safe Design12
Time PeriodMedian Catheter-Related Blood Stream Infection (CRBSI) RateIncidence 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 monts00.34
Over various time periods, the Median Catheter Related Blood Stream Infection (CRBSI) rate reduces in conjunction with the Incidence Rate Ratio:
Baseline infection rate of 2.7 with an incidence rate ratio of 1
Pre-Intervention infection rate of 1.6 with an incidence rate ratio of 0.76
0-3 months: infection rate of 0 with an incidence rate ratio of 0.62
4-6 months: infection rate of 0 with an incidence rate ratio of 0.56
7-9 months: infection rate of 0 with an incidence rate of 0.47
10-12 months: infection rate of 0 with an incidence rate of 0.42
13-15 months: infection rate of 0 with an incidence rate of 0.37
16-18 months: infection rate of 0 with an incidence rate of 0.34
Slide 23
Understand the
Science of Safety: What the Team Must Do
  • 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:
    • Standardize
    • Create independent checks
    • Learn from defects
A team conferring at a table.
Slide 24
Summary
  • 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
 
Slide 25
CUSP Tools
  • Daily Goals Checklist
  • Morning Briefing
  • Shadowing Another Professional Tool
  • Observing Patient Care Rounds
  • Team Check-Up Tool
Tools icon
Slide 26
TeamSTEPPS Tools1
  • 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*

Tools icon
TeamSTEPPS logo and penguin
Slide 27
References
  • Agency for Healthcare Research and Quality, Department of Defense. TeamSTEPPS. Available at http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html
  • Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29-34.
  • 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.
  • Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 349:309-313,1997.
 
Slide 28
References
  • Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
  • 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
  • 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.
  • Ending health care-associated infections, AHRQ, Rockville, MD, 2009. http://www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/index.html.
  • Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–57.
 
Slide 29
References
  • Heifetz R. Leadership without easy answers, president and fellows of Harvard College. Cambridge, MA: Harvard University Press;1994.
  • 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.
  • 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.
 
Page last reviewed April 2013
Internet Citation: Understand the Science of Safety Module Alternate Text . April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/understand/understandalttext.html