Patient and Provider Safety in Anesthesia dictated slides 1-50

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Patient and Provider Safety in Anesthesia:

Professor: Maribeth Massie, CRNA, MS, Ph.D.(c) ANE 507: basic principles of anesthesia I Patient and Provider Safety in Anesthesia

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 2 Cooper, J et.al. (1978) Preventable anesthesia mishaps: a study of human factors in anesthesiology . Anesthesiology; 49: 399-406 Gaba , D. M. (2000) Anesthesiology as a model for patient safety in health care . BMJ; 320:785. “…the practice of anesthesia - acknowledged as leaders in addressing issues of patient safety” Leape , Lucien (1994) Error in medicine. JAMA; 272: 1851-1857. WHY? Technological advances Providers tend to be risk averse & interested in patient safety Biomedical engineers involved with OR dynamics Relationship with aviation model Safety Goals

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 1970s – 1980s Major Drivers– During the 70s Malpractice insurance cost soar At risk for becoming unavailable Grass roots efforts with professional organizations to address patient safety AANA, ASA, AORN, ASPAN 3

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 4 Solution strategies developed Harvard Standards & Guidelines of care Eichhorn , J.H. Cooper, J. Cullen, D.J et.al. (1986). Standards for patient monitoring during anesthesia at Harvard Medical School, JAMA 256: 1017-1020. Similar standards adapted by ASA & AANA Looking at human factors Techniques – “critical incident” analysis [R/T aviation literature] Analysis of closed malpractice claims Australian incident monitoring study [AIMS]

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 5 1980s – 1990s 1985 - The formation of the “interdisciplinary” Anesthesia Patient Safety Foundation (APSF) James Reason – latent error model systems accidents Reason, J. (1997). Managing the Risks of Organizational Accidents. Brookfield VT: Ashgate Publishing.

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 6 Anesthesia Patient Safety Foundation (APSF) Newsletter – premier international publication on patient safety with the widest circulation of any anesthesia journal Research funding – in the first 18 years over 200 research publications resulted directly or indirectly from funding Celebrating 25 th anniversary of first publication

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 7 1997 - AMA created National Patient Safety Foundation (NPSF) 1999 – 1 st IOM Report – To Err is Human: Building a Safer Health Care System “Crystallized & focused national attention on the issue to the point that the Clinton administration mandated immediate & aggressive intervention.” Biddle & Lahaye (2003)

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 8 2000 – Present – Integrating simulation in education, CE, & remedial help programs 2004-05 – AANA added “patient safety” as part of the mission statement – “Supporting our Member – Protecting Our Patients” 2007-08 – AANA play integral role in intervening in the “re-use of syringe” crisis in Nevada & New York 2009-10 – AANA position statement on securing propofol

Patient Safety Movement Historical Perspective::

Patient Safety Movement Historical Perspective: 9 2009-11 – Hospitals & clinician-level performance measures tied to reimbursement to drive quality Surgical Care Improvement Project (SCIP) National Quality Forum (NQF)

Prevalence:

Prevalence 10 Studies conducted by Harvard researchers (1991): 3.7% of hospitalized patients suffer significant iatrogenic injuries, typically from errors &/or negligence According to Lucien Leape , there are “ 2 errors for every ICU patient every day” Mean of 1.7 mistakes per patient per day in ICU (out of 200 patient care activities) Even just a 1% failure rate should be Unacceptable! At a 99% success rate: From within the airline industry , there would be about 2 unsafe plane landings at O’Hare airport each day The US postal services would lose about 16,000 pieces of mail In our banking system , 32,000 bank checks would be deducted from the wrong account every hour

Prevalence:

Prevalence 11 44,000 – 98,000 deaths annually attributed to preventable medial errors 6 th leading cause of death in the US Most occur by way of “human error” Still not enough progress since 1 st IOM report (>10 years out) Continue to rely on the “traditional health care paradigm” – ‘the blame game’ mentality

Prevalence: Post – IOM Report!!!:

Prevalence: Post – IOM Report!!! Study released by Health-Grades (2004) [an arm of Agency for Health Research & Quality (AHRQ)] 1.14 million total patient safety incidents (PSIs) occurred among 37 million Using data - Medicare population between 2000 – 2002. Highest PSIs Failure to Rescue (failure to diagnose & treat in time) Decubitus Ulcers Post-operative sepsis 12

Prevalence: Post – IOM Report!!!:

Prevalence: Post – IOM Report!!! 13 Of the total 323,993 deaths of patients who experienced one or more Pt. Safety Incidents (PSIs), 263,864, or 81% were R/T PSIs Teaching hospitals > PSIs than non-teaching hospitals > PSIs seen with medical versus surgical patients From the 16 PSIs studied – they accounted for $8.54 billion in excess patient cost to Medicare system Decubitus ulcers ($2.57 billion) Post-op pulmonary embolism or DVT ($1.40 billion) Selected infections ($1.71 billion)

Public Opinion: Kaiser Permanente Study:

Public Opinion: Kaiser Permanente Study 14 Aim: Understand American’s beliefs about medical care Sample: 2012 Telephone survey respondents Attitudes Identified: 55% overall dissatisfied Many [still] underestimate the impact of medical errors 34% stated that they themselves or a family member had experienced a serious medical error in the last 5 yea rs, only 11% filed a suit against a professional or institution 70% were not informed by the [system] about the error 88% felt that disclosure should be mandated!! Most would pay more if disclosure was mandated to improve safety

Slide 15:

IOM defines error: “The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” & “Errors occurring within the healthcare system are almost always preventable” 15

Slide 16:

Skilled-based errors – ‘slips’ Rule-based errors – ‘wrong rule is applied’ Knowledge-based errors – ‘rare situation or not previously encountered’ Experience does not equate to higher clinical qualit y (Choudry et al., 2005) It takes 17 years for clinical practice to change (Balas & Boren, 2000) 16

Slide 17:

17 Clinicians, patients, families “Tools of the Trade” MISHAPS OCCUR HERE Employer, Health Care Org., Supervisors, Administrators, Policy Makers “Physical Infrastructure” Error may reflect influences of the System Media, Legislators, Corporations, Regulators, Accrediting Agencies, Educators Change starts here SHARP END BLUNT END Reason’s Model (1997 )

Accountability:

Accountability 18 Sharp end : Who did this? How did this happen? Usually practitioner Human error Knowledge deficit Lapses Ethics

Accountability:

Accountability 19 Blunt end : Why did this happen? Communication Complex system Redundancy

Slide 20:

20 “The value of history lies in the fact that we learn by it from the mistakes of others, as opposed to learning from our own mistakes…..” James Reason

Why do errors occur?:

Why do errors occur? 21 Some systems are more prone to accidents than other – because of the way the systems’ components are tied together Health care systems fall in this category ! – A complex & technologically driven system

Why do errors occur? Human error vs. System error:

Why do errors occur? Human error vs. System error 22 Active Factors: Human error falls in this domain – saying that an accident is due to ‘human error’ is NOT the same as assigning blame, because most human errors are induced by system failures

Why do errors occur? Human error vs. System error:

Why do errors occur? Human error vs. System error 23 Latent Factors: OR System failures pose the greatest threat to safety in a complex system [health care]. These are failures built into the system & are present long before an Active error occurs. They may be difficult to identify because they maybe hidden or layers of management & people accustomed to working around the problem Latent errors are oftentimes NOT foreseeable

Why do errors occur? Human error vs. System error:

Why do errors occur? Human error vs. System error 24 We tend to focus on active errors! Not always effective – many times just a “band aid” If system wide failures [latent errors] remain un-addressed, makes system more prone to failures

Beware of : “Normalization of Deviance”:

25 Beware of : “Normalization of Deviance” Defined - The accumulated acceptance of cutting corners or making work-arounds over time. From the aviation literature; Normalization of deviance is a long term phenomenon in which individuals or teams repeatedly accept a lower standard of performance until that lower standard becomes the “norm”.

Beware of : “Normalization of Deviance”:

26 Beware of : “Normalization of Deviance” Usually, the acceptance of the lower standard occurs because the individual/team is under pressure (budget, schedule, etc.) and perceives it will be too difficult to adhere to the expected standard.

Beware of : “Normalization of Deviance”:

27 Beware of : “Normalization of Deviance” Their intention may be to revert to the higher standard when this period of pressure passes.  However, by “getting away” with the deviation, it is likely they will do the same thing when the same stressful circumstances arise again.  Over time, the individual/team fails to see their actions as deviant.  Normalization of deviance leads to “predictable surprises” which are invariably disastrous to the team.

Beware of : “Normalization of Deviance”:

28 Beware of : “Normalization of Deviance” Examples: Reuse of syringes and needles – “the Nevada story” Not Checking equipment regularly Production pressure Not doing “time-outs” Ineffective patient assessment, especially difficult airway Labeling of syringes

When errors occur……:

29 When errors occur…… We should learn from them! Using Root Cause Analysis (RCA) Introduced to SRNAs early on in their program At NU - three threads in curriculum [patient safety, interdisciplinary practices, & cultural competency] We should look beyond the event We should avoid placing blame We should reward honest reporting We should design a safer system

When errors occur…… :

30 When errors occur…… Root Cause Analysis Report event without blame Gather data & evidence Interviews (debriefing) Chart review Observations Analyze data & evidence Identify active factors (human error) versus latent factors (system error) Suggest policy change Enact changes

Strategies::

31 Strategies: Traditional Model - Ineffective Individual accountability No errors acceptable Being careful & smart is not good enough Errors/incidents corrected with re-training &/or punishment Culture of error based on blame – shame paradox

Strategies::

32 Strategies: New Patient Safety Paradigm - Effective Healthcare is inter-disciplinary [intra-disciplinary, trans-disciplinary] Human errors are expected Even the most careful & smartest clinicians can make mistakes Many adverse events are preventable Correction of a system’s issue is facilitated by transparent reporting Legal disciplinary immunity granted for voluntary reporting Report incidents & learn from them!

Strategies::

33 Strategies: Value of Error Reporting - Chronology Traditional M & M (prior to 1980s) Quality Assurance & Risk Management (early 1980s) Systematic, multidisciplinary review (late 1980s) Root Cause Analysis (RCA) [1990s] National repository (late 1990s to NOW)

Strategies::

34 Strategies: Error Reporting Systems – Many types, all can be effective Voluntary or mandatory Institutional based Private agencies (i.e., consultants) Government agencies Accrediting bodies Scholarship Informal (unstructured)

Strategies::

35 Strategies: Current Reporting Systems TJC: Severe injuries – “benchmarks” VA: Adverse events & injuries FDA: Med-watch (drug errors & equipment) & Transfusion blood products NPDB: National Practitioner Databank State Regulators: BOM, BON, & DPH PPOCA: Pediatric Peri-Operative Cardiac Arrest (anonymous & confidential)

Strategies::

36 Strategies: Technological advances Advanced Initiatives in Medical Simulation (AIMS) Automated Anesthesia Record-Keeping Systems ( AARKS) Medication bar coding Health Financial Systems (HFS) Ease of access to literature Clinical Decision Support System (CDSS)

What’s being done?:

37 What’s being done? Patient Safety Bill – US Congress (2005) Mandatory Reporting System of serious events Voluntary Reporting System of other events Reports are distributed to “Patient Safety Agencies” Reports are discovery protected & names & identifying information is not available Patient Safety Agencies study the reported data, & make recommendations for policy & standards of care

New initiatives……………:

38 New initiatives……………

New initiatives……………:

39 New initiatives…………… Center for Medicare/Medicaid Services (CMS) CMS “pay for performance” – among providers based on clinical practice measures “ g-codes” Voluntary reporting system (as of January 2006), where anesthesia has 3 codes: Prophylactic antibiotics 60 minutes before incision Normo-thermia documentation Pain management documentation by ASA standards ???What about monitoring “awareness”???? STAYED TUNED!!!!!!!!

New initiatives……………:

40 New initiatives…………… AANA EBP – Process Project GOALS: Best evidence Clinical expertise Patient values/preferences must be the focus (tailored-care)

How?:

How? Define what evidence-based nurse anesthesia practice is for the profession Identify critical components of the EB process and how to handle various issues Are there current models that could be adapted for use by the association? Required steps for a thorough process? How to assess priority to an issue?

How?:

How? Developed a project timeline of 10 months (completed in 2009) Educate members on the concepts/principles of EB practice Literature search on the concept, exploration of current definitions of EB practice across multiple disciplines Nursing, medicine, psychology, sociology Qualitative discussions regarding where nurse anesthesia and CRNAs fit within the EB practice arena

Definition of NAEB practice:

Definition of NAEB practice “integration and synthesis of the best research evidence with clinical expertise and patient values” in order to optimize the care of patients receiving anesthesia services”

Slide 44:

Based on Stephen Covey’s Time Management Matrix Seven Habits of Highly Effective People

New initiatives……………:

45 New initiatives…………… IOM Report on the Future of Nursing: Recommendation: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions:

IOM Recommendation…. For CONGRESS::

IOM Recommendation…. For CONGRESS: Expand the Medicare program to include coverage of APRN services that are within the scope of practice under applicable state law, just as physician services are now covered. Amend the Medicare program to authorize APRNs to perform admission assessments , as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities. Extend the increase in Medicaid reimbursement rates for primary care physicians included in the Affordable Care Act (ACA) to APRNs providing similar primary care services. Limit federal funding to nursing programs in states that have adopted the National Council of State Boards of Nursing APRN model rules and regulations (Article XVIII, Chapter 18). 46

IOM Recommendation…. State Legislators: CMS::

IOM Recommendation…. State Legislators: CMS: Reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing APRN model rules and regulations (Article XVIII, Chapter 18). Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to APRNs who are practicing within their scope of practice under state law. Amend/clarify the requirements for hospital participation in the Medicare program to ensure that APRNs are eligible for clinical privileges, admitting privileges, and membership on medical staff. 47

IOM Recommendation…. Federal Trade Commission & the Antitrust Division of the Department of Justice:

IOM Recommendation…. Federal Trade Commission & the Antitrust Division of the Department of Justice Review existing and proposed state regulations concerning advanced practice registered nurses to identify those states that have anticompetitive effects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so 48

Take home points………………..:

49 Take home points……………….. Be aware of new trends & initiatives – both nationally, regionally, & locally! Simulated CE programs to improve practice Some states (i.e., Florida) require patient safety CE programs for re-licensure Risky practice behaviors – R/T “vigilance” & “fatigue” & working long hours, & normalization of deviance….. Handing off of care - Are we providing sufficient information in reporting? Mandatory versus voluntary reporting of errors Learn and use EBP guidelines

Take home points………………..:

50 Take home points……………….. Does your practice setting support the patient safety movement? Try to get involved at the local level Appointment to a hospital-wide “safety committee” OR within the Operating Room itself We need CRNAs involved with credentialing committees [currently, very few are] We need CRNAs in healthcare/policy leadership positions AHRQ – Instrument to measure “Safety Culture in Hospitals” – You may see this tool being used in a variety of studies on patient safety!

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