Denenberg, Matthew, MD, FAAP, FACEP, Medical Director and Division Chief, Pediatric Emergency Department

Hackbarth, Richard, MD, Pediatric Clinical Care (Helen Devos Children\u27s Hospital), Assistant Professor in the Department of Pediatrics and Human Development (Michigan State University College of Human Medicine)

Rechner, Stephen, MD, Medical Director, Women\u27s Health Services

Rodriguez, Carlos, MD, FACS, Medical Director of Perioperative Services (Spectrum Health), Assistant Professor of Surgery (Michigan State University College of Human Medicine)

English

Scholarworks@GVSU

ED CPOE Experience Matthew Denenberg, MD "'"CT"< " HC.«," Objectives , ReView how CPOE has impacted patient safety in the ED Review the basic safety benefits CPOE of CPOE Review the safety concerns associated with CPOE Before CPOE After CPOE Home Folder WIthPaper orders departmentand order sets specific order setsiPowerplans Why Do CPOE? More than one million serious medication errors oCCur every year in U.S, hospitals Medication eITOrs alone contribute to 7,000 deaths annually Financial costs. One ADE adds more than $2,000 on average to the costs of hospitalization. This translates to over $7,5 billion per year nafionwide in hospital costs alone, 1-_..__..__ .._____     __5_P"CT_'.U"':_,H;_ Why Do CPOE? -------------..-Standardize process (check lfst of items to remember for each condition) Real time rules and alerts at ordering. signa! drug Interaction, allergy or dose errors Eliminate delays to downstream departments with real time order processing Enable bar code medication administration Dose calculators and other electronic tools to asslst in accurate dOSing Order sentences eliminate sound alike drug errors Clearer communicatIon between physicians, nurses and pharmacists Order hieroglyphics? ( Orders easily legible and found electronlcall y Before CPOE After CPOE ..  ,.. .... If"  I>  Before CPOE Hand Written orders sit in paper chart to be transcribed into Cerner After CPOE Physician can order electronicall y from anywhere they can access Cemer Before CPOE Pharmacist Transcribing handwritten, often Illegible, medication orders " IOc • 2 After CPOE             <!j                                        !J                                      1: &1                                                                              1-    .....                                         1-    Pharmacist reviews electronic orders in Pharmnet U)r!il101HI OlnVC1,$                        "'",... XJflln(,mOO w"                              ,",' • ,.. ., ..  lie ..  ., II" ., " ... ..  -{ <,-,SPECTRUf1 HEALTH c                               Before CPOE AfterCPOE Hand Written Discharge Instructions Printed Electronic Dischar e Instructions SPECTRUM             . Before CPOE Hand Written Prescriptions After CPOE Printed (legible) prescription or prescription sent electronically to pharmacy (e-prescribe) Previous clinical references • Cefazolin adults 3 SPECTRUM                  Difficulties experienced in ED Cu:ture change by providers  Decreased direct communication  Software limitations  Education, there is a steep learn[ ng curve  Real time and order processing very quick  Real-time evaluation with ability to update quickly  Clinical updates  Safety issues  Efficiency upgrades  ,. SPECTRUM                      Spectrum ED Experience Over 200 physicians, extenders and nurses entering orders. Despite steep leaming curve and frequent obstacles along the way, very few providers would elect to "go back". SPECTIlUM HEAlT;;-" CPOE Safety Recommendations Robust education before. during and after "Go Live" events Extensive IT support staff with real time response Hardware and software able to support CPOE Monitor before and after "go live" to research effectiveness Continuous review and updafing of system to accommodate provider concerns and new clinical evidence Most importantly, monitor and correct unanticipated safety errors " ..  ..  ,. SPECTRUM                        Spectrum ED Experience 4                                    children's hospital Communication and Safety: The  Pediatric Intensivist's Perspective  Rick Hackbarth, MD  Pediatric Critical Care  Helen DeVos Children's Hospital  Safety Culture and Communication •  How safe are we? • Similar to a group of Children's Hospital PCCUs when compared by risk adjusted mortality and other measures. •  How safe could we be? • Unknown ttele,                  children's hospital Group Pyschology Group Perception = Reality ¥Truth ·Galileo's Solar System ·Stock Market Variability ·Real Estate Crash                        chlldren'ShOSp(lal Disclaimers and Credentials •  Disclaimers [have no forrnaltralnlng In safety I have no forrnaltralnlng in psychology I am not an expert In communication I m stili gOing to talk about all of them •  Credentials I'm old enough to have made lots of mistakes (experience) Tend to be dissatisfied with the Status Quo and vocal about it I'm a physIcian (least Important perhaps completelyrrelevant) Itelen 'DeVoe;    children's hDspjtal The ICU Environment • Complex, high stakes, high risk • Critically ill patients with rapidly evolving or changing pathophysiology •  Frequent use of high risk medications (15 of the top 20 error prone pediatric IV medications) •  Fast paced environment with multiple disciplines involved requiring frequent updates in communication that maintains fidelity across team members /tele" 'DeVoe;    children's                    D\..\::::') PICU Safety Attitudes Questionnaire Results for 2007 and 2008 :'00"'.' 01                                                                                          Sc"," ..                                            • Strlwtol", "'"lCORtOlb 10 ol",-...,lthnchc leohurve talres3 T._.rtCllm.eljporuiwdqu..iIy.lc.a.bG.....n)!I<-1I1 _ ....._,_"'..__                     ............... _......-.____71,."j I_...         __ __" .......,-7_1+'1)   ..__,.;,..,. .. .,.........           __   __ :;I;;n :...,...-::::.:-- ..             ..         SIIe!yCI".",.", .... oIwd:llfol>g/p«Jodive<o_iIlII...tt••aIoIy)lIt') 1_1IoI_..... _ .......p_             1_1IIo'"_..._ ..                       •..,..._ ... Jl"" "'..__ ... ..,... _ .....11"" 1... ___ ty",, __"'..,......,p_.......-IIIIIf_                                             ........,,-J.l>hllsbdion(p.tkm/y...utth..."' ....lI1enct)"«2) IIiIoo000joIIJlr1J 1.. ,.....1._............... 1'(>4)   .......pI_.. _                             ...... r.n.Ij li·PL""III..                                                                                n"" H..,...___---.,._....                            10<',< ' ...........""'"'Y ......... _ ..,,""lhlIIh*Iy'"",,-IIoopitaI.....,",." 1..._01-,. ...... _ ......._10_...-.01'_ 19(.1) HoopoI>I.................._""• ..,. .._                     I         'r 1 Survey Comments a team and we have severe trust Issues with one ') feel that there are certain "chques'lt"1at eXist and! am r;Qt a         of those and therefore mYlnput is not cor:sldered worth                   to_' Why Safety Culture and Communication Matter Group Perception = Reality .'  Safety Survey Results • Communication is a problem • Poor safety culture • Impaired Teamwork-• Attitude of: I want to bell am safe, but I don't trust that my co-workers have that priority No sense of family ... .. •  ... ..  ..  Safety Survey Results • Does Safety Culture Matter? • Does Communication Matter? tteiel'l PeVa(    children's hospital itele, PeVa,    chl:arcm's t'lospltal Safety Culture and Communication • Individual accountability and desire for safety • A good start but leading by example is not enough • Group accountability and teamwork • Essential for safety to have each others back and to ask for help Safety Culture and Communication • Just how important is a good team? -Cinderella team? Maybe -Few standouts -Strong team culture -Nearly won NCAA Chaf'1plonship agamst a more talented Duke Team •  ..  • /II> III  II  ..  ..  " .,  "  Itt •  2 lit .. III Joint Commission- 2004 Perinatal Sentinel Events Permanent injury or death root cause analysis of 47 cases • Communication Issues (72%) • Safety Culture (55%) • Staff Competencies • Orientation and Training Issues (40%) Effective Communication Across the "Authority Gradient" r;    &'. iJ "     .. : _.    '-. " ,; J                    .:                  t op . 11 l c _ .     ._ a.;4;.t..). .. You've Gotta So what have we done about it? Believe! • Focus on communication • In everyday practice •  In mandatory PCCU staff safety updates across all disciplines- • Accentuate the positive • Quality improvement initiatives • Encourage staff involve men t o • Great Expectations • Goals v  • Projects Has it worked? •  The change in attitude seems palpable • Time will tell with more objective measures Communication Top 10 If yQV are n(./VOCil:l11tg lot YOWf                   no on., con Tau!! )lUI: 3 Acknowledgements I' Thanks to Our Great Team at HDVCH -The Future of Highest Quality and Safest Care In West II' Michigan " 'II!' " " III, " .. ". ." .. ..' ,. " '" IF .. II' .. .. II" .. .. II, " .. 4 • ..                                    Safety Culture From Another Perspective Stephen Rechner, MD Medical Director, Women's Health Services May 26, 2010 .... *"I' Disclosure Regrettably, I have nothing to disclose.. , ..                                                      The Crew - - ....              7S84 Objectives                                                To understand the importance of: • Checklists in emergency situations • Simulations and drills • Team work in emergency situations The Use of Checklists -Checklists • Walk Around with Crew C range • Before             Engine • Start              • Before Taxi • Taxi • Take Off • Level Off  ft;... '.c,ccou,· Hei .•". Emergency Procedure Checklists (08) ........--Shoulder Dystocia: 1. CALL FO'< HELP 2. MCROBERT'S MANEUVER 3 REFER TO CHECKLIST .... -----------Simulation and Drills (08) :::,'t.:               ... ";'L,:",'    Emergency Procedures Checklist Engine failure or fire during flight 1 THROTILE - CUT OFF       FI.'<E SWTCH -          3 REFER TO CHECKL:ST ..-                  ..                            Simulation and Drills • Swiss Cheese Model DETECT t. CORRECT                                                  .' <I Ill' .-.. ..  ,.  • ,. ll-l' • • .. .. ., ,. ., I' .. III' II .. • III' iii .. .. '" 2 '" " II-ARCC A responsibility to protect In a manner of mutual respect -an assertion and escalation technique Use the lightest touch possible" Ask a question Make a Request Voice a Concern  If no success  Use Chain of Command                                                 99,9% is Not Always Good Enough IRS woulo lese 2,00C,JOO docemerls everJ year ATWs would make 37,000 errors every hOLr Major plane crash every 3 cays 12 babies given 10         wrorg parents every day 107 wrong medical prOCeGures per day • 3 II' II' ..  ..  t, ..  .. ..:., SPECTRUM HEALTH', 2010 The Year of Perioperative Safety Safety is Everybody's Job in a High Reliability System               Rodrig\<cz MD Anoc:at.. Mudica' Ott"d", P"r.,perabv& s.e'Vices • " SPECTRUM HEALTH"',-2010 Periop Safety Goals To have no Senous Safety Events occur To have open and valued communication amongst the Penoperative TEAM At each point of patient handoff, pertinent and up to dale infomlation is reviewed amongst care givers Consistent use of F:'erioperative             tools SUGh as the satety checklist. policIes, safety roundmg and safety audits DIStractions at an pOints of patient care are Ilmi1Cd Attention and fOGus of our work is directed toward the patient All regulatory expectations are met consisientt; i...eapfrog, SCtP and IHI expectations are met conslstent¥ Share ,safety incidents with Penoperative Services members to Improve care, Increase awareneSS and educate • SPECTPUM Preoperative Checklist On Odober30. 1935 at WtighlAir Field in Dayton, Ohio the first test flight of Boeing's Model 399 resulted in a fiery crash ... The crash was blamed on the Army Air Corp's best lest pirot Major Ployer P.HilL This plane was deCidedly more complex than previous aircraft ...                                                                  • Preoperative Checklist Insiders and other test pilots felt that the plane was flyable They came up with a ciever and simple idea They created a pilots checklist. They felt that aeronautics had become so complex that they could no longer rely on Just the memory and experience of the pi lot however much an expert. • SPi'CTIllI"                Preoperative Checklist The rest as they say is history ... U.S. history that IS .. The                     allowed for many successful and safe test flights ,Model             the B-17 'Fyrng Fortress"                           almost 13,000    ..,,' The B-17 gave the Alhes a decided                     over the skies of Europe and its bombing campaign had devastating effects across Nazi Germany • I Of course, checklists have been around for a long time... Could this be a grocery list from ancient Egypt? SP£::mGM                Preoperative Checklist Our checklist was initially conceived because of our need to improve our SCIP numbers and to drive up perioperative safety ... It went along with our desire to "hardwire" some orders and to make sure they were carried out.., The work of the WHO and their landmark study in the NEJM also drove the issue...         media and public opinion also played a rOle.• "', Preoperative Checklist We formed our checklist by taking the best components of: WHO and Gunderson Lutheran Please refer to your handout for the details of the current Spectrum Health Preoperative Checklist., , This list is being constantly evaluated and improvements are being made ... • _. Preoperative Checklist Like in the 6-17 example, medicine and nursing as a whole particularly those involved in the field of surgery, have had to  develop the ability to manage extreme complexity.  Can this complexity be mastered? Yes, Checklists are not the total answer to the question bu! they can certainly help with the execution and the process of SAFETY. We need to overcome faulty memories and distraction .. Checklists "instili a kind of discipline of higher performance" and "provide a kind of cogmtive nef says Atul Gawande in his book "The Checklist Manilesto-How To Get ThIngs Rlghf",2009 -PREOPERA TIVE CHECKLIST EQUALS PERIOPERATIV'A, SAFETY- .. r--Preoperative Checklist r--We looked at and assessed the value of same existi'1g published checklists from other institutions"" -The SCOAP IisL The Foundation for Health Care Quality -Regions Hospital -United Health Services Hospital -Children's Hospital of Boston -Mayo Clinic -Gunderson Lutheran -World Health Organization -We also reviewed multiple videos of checklists in action. •  Preoperative Checklist _ ...... The list consists of 3 Phases Some refer to these as "Pause Points" -At sign in ... Before induction of anesthesia -Time out.,. Before skin incision -Sign out. .. Before patient leaves the 0 • II' , 11" ..  .'  " ,  ..  III" " II' .. • ... II" " ,.... ., « ,.  I> II" '" " *' ..  ..  2 ,.. .. 111 II Preoperative Checklist Do-Confirm vs, Read-Do Checklists We chose the Do-Confirm", We expect those in the OR to perform their jobs from memory and experience, then as a team confirm that it has been done, We're striving for early and on-going communication ... This has been found to be more professionally satisfying and does not lead to list "shortcutting"as eventually occurs with Read-Do Checklists. Our Checklist is intended to Increase and enhance communication among ali OR team members ... • .'::. "n ",' Preoperative Checklist We began with several checklist "pilot trials" performed by surgeons and anesthesiologists" ... This led to a refinement of our checklist. .. More importantly it introduced the concept of the checklist to the OR staff and led to discussions amongst surgeons and anesthesiologists., . " • Preoperative Checklist      The"Surgical Safety Checklist" as it is now known went "Live" Dec, 1,2009", Prior of going "live" it first underwent 6 wks of trials and adjustments to both document and process using both nursing and medical staff feedback" "Go Live" consisted of mandatory use of the cheCKlist and optional retum of the physical list that highlighted issues both positive and negative as well as suggestions for Improvement Large laminated versions (11x22 in) are now posted in all SH ORs as a visual reminder and guide for its use" • C---. ____ __ Preoperative Checklist The checklists that are returned are collected and logged into a database ... Comments are categorized and monitored for systemic problems .. Daily rounding by nursing leadership is also underway. ".this provid.es us With a chance to observe the checklist process and proVIdes teaching and guidance... Feedback related to undesirable behavior or pushback about the checklist are referred to the appropriate leadership: Nursing, Surgery, or Anesthesia ... Many                       discussions have taken place .. All feedback and usage statistics are published twice/month to all                staff The Peri-op $taff is responding well to the p.ubljShed data as they _ results of their engagement In the process.. 1IIlI" Preoperative Checklist: Next Steps                               -------1                                                                                                                                  Staff communication regarding changes In expectations wEi be done in advance ... V\Mh next "Go             we will have mandatory return of all  checklists ... each checklist wfll have a patient sticker or be pre-printed  with patient name ... Feedback js sWI opttona!, BUT ...  We will begin to collect specific data regarding the level of team  engagement in the process.  Again we will cont'nue to collect any feedbaCK from staff and report back to them ..   are planning a ;20 day review of the process additional             ... Will be made as feedback and data warrants .. , .. Preoperative Checklist Unintended consequence of CheCKlist? Supply Chain recentiy raised a concem about the spike in volume of returned items from the OR starting in November and increasing in December., This COincided with the implementation of Checklist trials" ,our feedbaCk from staff included a disproportionate amount of comments about how to do the case in a more cost effective way,,, We will monitor to see if this trend continues .. • 3 ,'f:>"'c,' Preoperative Checklist Progress? Herding cats".  Good acceptance among periop nursing staff..  Slower going but gaining momentum among surgical  and anesthesia staff ...  It will take persistence, more education, and continual  communication to get full cooperation.,.  Even a year into the program, we are still a work in  progress .... refinementscontinue ...  .. • "  ,.. 4 

Role of Interprofessional Teams in High Reliability Systems

http://scholarworks.gvsu.edu/ipe_conference/2011/Panel/1

Role of Interprofessional Teams in High Reliability Systems

Abstract

Similar works

Full text

Available Versions

Scholarworks@GVSU