Faculty Learning Module 17

Patient Safety: Our intent is to do no harm – so why do errors happen?

Introduction

The significance of errors in patient care has been highlighted in the literature and media since the 1999 sentinel work of the Institute of Medicine entitled To Err is Human: Building a safer health system. Using QSEN competencies to prepare students to be vigilant around patient safety and to understand the impact of errors, this module will share examples of patient safety, just culture, and will share some pedagogies using simulation to allow immersion into teamwork and collaboration to promote safe patient care.

Objectives

Upon completion of this section, you will be able to:

• Recognize the impact of errors on patient care, patients, families and healthcare providers

• Describe processes used in understanding causes of error and allocation of responsibility and accountability

• Describe the importance of interprofessional teamwork communication and collaboration in the integration of care and its impact on patient safety

• Delineate the steps in error disclosure from risk management to transparency

Contributors

• Carol F. Durham, EdD, RN, ANEF

• Jennifer Dwyer, MSN, RN, BC, CNRN, FNP BC

Content

Patient Safety: Our intent is to do no harm – so why do errors happen? is situated in the context of the impact of errors on patient care, patients, families and healthcare providers. Using actual medical errors, the processes used in understanding causes of error and allocation of responsibility and accountability will be described. Medical errors have many contributing factors, yet interprofessional communication and collaboration continue to be cited by the Joint Commission as the leading cause of sentinel events. TeamSTEPPS will be the framework for teaching effective interprofessional teamwork communication and collaboration techniques. Using collaborative teamwork and effective communication are crucial to providing opportunities for learners to understand how to work together versus working in isolation and creating fragmented care. Once an error occurs, the next steps are essential for promoting patient safety. We will delineate the steps in error disclosure from risk management to transparency.

Effective teamwork and collaboration is not easily taught using the more traditional approaches like discussing teamwork and communication in classroom even with the presence of interprofessional students. The learners need the opportunity to be immersed in patient care simulated experiences which allow learners to rehearse effective communication techniques. In this module we will explore current teaching practices that enable and/or inhibit students to be collaborative practice-ready when they enter practice settings.

Patient Safety: Our Intent Is To Do No Harm – So Why Do Errors Happen?

[video coming soon]

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Resources

• Videos

• Handouts

• Teaching Strategies

• Web Resources

• Bibliography

Videos

Just Culture – How Medical Errors Promote Patient Safety

The following video, referenced throughout this module and available to us courtesy of Indiana University Health, captures a Patient Safety presentation by Cindy DeBord, RN.

The full presentation includes a copyrighted video that provides a simple illustration of how we observe environments and demonstrates selective attention. This video, available on Youtube, is listed below between the first and second parts of the full video of the presentation. Please note that the outcome of watching the selective attention test video is discussed in detail at the beginning of Part 2, so for best effect, watch the videos in order.

• Full Video, Part 1 (05:26)

• Selective Attention Test (1:22)1

• Full Video, Part 2 (33:44)

Sections of this Just Culture video are linked from within the module content. Those clips are listed below for ease of access:

• Video Clip 1 (00:19 – video is no longer available

• Video Clip 2 (03:09) – video is no longer available

• Video Clip 3 (04:55) – video is no longer available

• Video Clip 4 (00:31) – video is no longer available

1The Selective Attention Test was developed through research conducted by Daniel Simons and Christopher Chabris in 1999. More can be found at their website (www.theinvisiblegorilla.com). The video is available for use in talks, training, and teaching on DVDs from Viscog Productions.

Handouts

Patient Safety Starts With Me!! A printable bookmark (PDF) to keep patient safety at the forefront. Used with permission from Indiana University Health.

Teaching Strategies

The following are QSEN Teaching Strategies referenced in this module.

• Nurse-physician Communication Exercise

• A novel Format for Students Post conference and teaching SBAR communication

• Using a Fishbone (Root Cause Analysis) (RCA) Diagram to Problem Solve Falls

Web Resources

Agency for Healthcare Research and Quality (AHRQ) This website has a wealth of information and resources including information on evidenced based practice, relevant research, patient teaching information, and consumer information around quality and safety. http://www.ahrq.gov/

Web Mortality & Morbidity Cases on the Agency for Healthcare Research and Quality website: http://www.webmm.ahrq.gov/.

Kimberly Hiatt’s Story “Nurse’s suicide highlights twin tragedies of medical errors”

Institute for Healthcare Improvement (IHI) The IHI is a not-for-profit organization leading the improvement of health care throughout the world. IHI website has information about programs, links to patient safety information, including the IHI Open School: http://www.ihi.org/IHI/

Institute for Safe Medication Practices (ISMP) The ISMP is a nonprofit organization that educates healthcare providers and the public about safe medication practices. It has a plethora of resources for safe medication practices. http://www.ismp.org/

Institute of Medicine Health Care Quality Initiative The Institute of Medicine (IOM) (http://www.nationalacademies.org/HMD) is a nonprofit organization that provides science based information about health and science policy.

• To Err is Human: Building A Safer Health System (1999)

• Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

• Health Professions Education: A Bridge to Quality (2003)

• Keeping Patients Safe: Transforming the Work Environment of Nurses (2004)

• Preventing Medication Errors: Quality Chasm Series (2006)

International Nursing Association for Clinical Simulation and Learning (INACSL) Promotes research and disseminate evidence based practice standards for clinical simulation methodologies and learning environments. http://www.inacsl.org/

Joint Commission Accrediting body for many health care organizations, concerned with improving the safety and quality of patient care. http://www.jointcommission.org/

National Patient Safety Foundation (NPSF) The NPSF is a not-for-profit organization whose mission is to improve the safety of patients. http://www.npsf.org/

Quality and Safety Education for Nurses (QSEN) The quality and safety competencies are: patient-centered care, teamwork and collaboration, evidenced-based practice, quality improvement, safety, and informatics. Knowledge, skills and attitudes for pre-licensure education are outlined to clarify each competency. This site is a valuable resource because it also offers free downloadable teaching strategies and annotated bibliographies for each of the QSEN competencies. http://qsen.org/ Be sure and explore the Teaching Strategies and Learning Modules!

The Future of Nursing: Leading Change, Advancing Health Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (October 5, 2010). Retrieved from http://nationalacademies.org/HMD/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx .

The Simulation Innovation Resource Center (SIRC) National League for Nursing The SIRC is an online e-learning site for nursing faculty to learn about simulation and ways to integrate it into their curriculum. It provides various ways for faculty to engage with experts and peers. http://sirc.nln.org/

Society for Simulation in Healthcare (SSIH) Purpose is to strengthen patient care through simulation education and research. http://www.ssih.org/

TeamSTEPPS® [Team Strategies and Tools to Enhance Performance and Patient Safety] teamwork and communication curriculum developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ) http://teamstepps.ahrq.gov/

When Things Go Wrong: Responding to Adverse Events A consensus statement from the Harvard Hospitals that provides a format for error disclosure including emotional support to patients, families and clinicians involved in serious medical errors. http://www.macoalition.org/documents/respondingToAdverseEvents.pdf

Bibliography

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey Bass.

Durham, C. F., & Sherwood, G. (2008). Educational approaches to bridge the quality gap. Journal of Urologic Nursing, 28, 431–438

Kardong-Edgren, S., Adamson, K. A., Fitzgerald, C. (2010). A Review of Currently Published Evaluation Instruments for Human Patient Simulation. Clinical Simulation in Nursing 6(1), p. e25-e35

Marx, D. (2007a). Just Culture Training for Health Care Managers.Plano, TX: Outcome Engineering, LLC.

Marx, D. (2007b), Patient Safety and the “Just Culture”. Plano, TX: Outcome Engineering, LLC. http://www.health.ny.gov/professionals/patients/patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf

Sherwood, G. & Barnsteiner, J. (2012). Quality and Safety in Nursing: A competency approach to improving outcomes. Hoboken, NJ: Wiley-Blackwell.

Sullenberger III, C. B. & Zaslow, J. (2009). Highest Duty, New York, NY: HarperCollins e-books.

Discussion

After you have reviewed the module presentations and resources, consider how this material is relevant to your own work and experience. The following is a list of questions for self-reflection or for use in discussions with colleagues.

1. Reflecting upon courses in your curriculum, how do learners experience teamwork and collaboration? Are there experiences learners currently have that could be tweaked to be interprofessional?

2. What are the barriers we face in preparing learners to understand error, near misses and the role communication and collaboration have on the quality and safety of patient care? How might we create ways to weave safety and communication and teamwork immersive experiences into our courses?

3. What’s one thing I could try in my class tomorrow that would help my learners appreciate the issues around patient safety and errors?

4. What strategies have you already tried in the courses you teach that help learners understand patient safety, errors and their role in creating a culture of safety?