Measuring and Improving Patient Safety - Dr. Bursua

How are errors/risks identified and quantified?

- Voluntary error reporting

- Trigger tools

- External sources and reports: ISMP

- Retrospective chart audits

- Observations/ audits

What are the benefits of voluntary error reporting?

- Can be anonymous

- Utilizes end-user knowledge

- Can identify what is important to staff members

- Can allow for protected review

- Allows for qualitative interpretation of risk

What are the downsides of voluntary error reporting?

- Low sensitivity

- Dependent on culture

- Can be weaponized

- May not identify most important risks

- Leads to problems when used to quantify risk

- Often misinterpreted

What is a trigger tool?

A trigger tool describes the process of using a "clue" in available collected data or metadata to identify patterns consistent with adverse drug events.

What are 2 examples of trigger tools?

- Naloxone after an opioid administration

- BG < 50 after insulin

What is the trigger tool workflow?

- Trigger event occurs

- Validation/ investigation

- Root cause pattern detection

- Targeted process improvement

- Metrics developed to determine if improvements are working

What are pros of trigger tools?

- More objective

- More dependable for risk quantification

- Can be used to detect outcomes of interest

- Can be used to measure performance of interventions

What are cons of trigger tools?

- Not easy to build

- May have limited sensitivity

- May have limited specificity

- Not available for all adverse outcomes

- Can be time consuming to employ

What is a retract and reorder trigger?

Adelson + colleagues devised a way to identify the occurrence of wrong patient near miss errors

What is the downside of a retrospective chart audit?

- Extremely time consuming

- Problems with inter-rater reliability issues

Observations/audits are subject to the ______ effect.

Hawthorne - tendency for subjects to alter their behavior when being observed

Voluntary error reporting is more useful in ______ (qualitative/quantitative) analysis.

Qualitative

Trigger tools are more reliable for ____ (qualitative/ quantitative) analysis.

Quantitative

Process measures focus on the ___ (how/what).

How

What is an example of a process measure?

Hand-hygiene compliance rates (actions used too achieve a desired outcome)

Outcome measure focus on the ___ (how/what).

What

What is an example of an outcome measure?

Patient satisfaction score (the final results)

What are the key differences between outcome and process measures?

Focus: Process focuses on the steps taken to achieve a goal while outcome focuses on the results achieved

Timeframe: Process focuses on the short term while outcome focuses on the long term

Control: Process focuses on something directly controllable while outcome focuses on something influenced by multiple factors

Example question: Process measure asks are we doing things the right way while outcome measure asks did we achieve the desired result?

What are the "Donald Norman User Centered Design" six strategies?

- Make important information visible (but be sure to eliminate unnecessary information)

- Simplify the structure of tasks

- Affordances and natural mapping

- Use constraints (forcing functions) to guide the user

- Make it easy to reverse error prone operations and hard to carry out non-reversible ones

- Standardize and simplify actions

What case study did we talk about for simplifying the structure of tasks.

Delays to reversal of ICH --> turnaround time for delivery of prothrombin complex concentration was found to be prolonged

What is an affordance?

A characteristic of equipment that communicates how it is to be used

What is natural mapping?

Intuitive relationship between the control and its function

What error required simplification?

Error related to the incorrect use of epinephrine for the treatment of anaphylaxis

What is an example of making it easy to reverse error prone operations?

"Are you sure you want to delete WINDOWS?"

What's more effective? System oriented solutions or human oriented solutions?

System oriented solutions!

What is the hierarchy of interventions?

Forcing functions -MOST EFFECTIVE

Automation

Simplification and standardization

Reminders, checklists, and double checks

Rules and policies

Education and training - LEAST EFFECTIVE

What is the "nudge theory"?

People often choose what is easiest over what is wisest

What is a nudge?

A strategy to alter people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives.

Are nudges mandates?

No, they do not impose material costs but instead alter the underlying choice architecture

What helped increase retirement plan contributions (we're talking about nudge theory here)?

Having a default option rather than no default option

What is the mantra of traditional solutions?

"Rational beings make rational decisions"

What is a nudge solution?

Modifying choice architecture to nudge prescribers towards the desired behavior

What does PDSA stand for?

Plan - Do - Study - Act

What are the 6 components of managing an improvement?

- Seek high-level, visible sponsorship

- Identify Stakeholders

- Plan for resistance

- Communiate/educate

- Share data

- Share successes

What are the 5 components of the Six Sigma and DMAIC?

- Define

- Measure

- Analyze

- Improve

- Control