Page 65 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

34 PART 1: An Overview of the Approach to and Organization of Critical Care

in a patient safety infrastructure. As our understanding of how to improve
TABLE 5-1 Comprehensive Unit-Based Safety Program 34
patient safety has grown, so has our realization that the current admin-
Pre-Post CUSP Complete survey at baseline and annually after CUSP implementation to istrative framework is insufficient to support safety efforts. As a result,
evaluate domains of culture (safety, teamwork, job satisfaction, unit-level many patient safety efforts fail to achieve their intended goal. A safety
and hospital-level management, stress recognition) infrastructure needs
CUSP step 1 Educate staff: view Science of Safety multimedia educational materials • A sufficient number of qualified clinicians in an ICU to provide
care (eg, intensivist staffing, nurse to patient ratio)
CUSP step 2 Frontline staff identify safety issues (provide mechanism for incident reporting)
• Clinical leaders and administrators trained in the science of
CUSP step 3 Partner with senior executive, schedule monthly meetings on the improving quality and safety 42
unit, discuss new and outstanding safety issues and potential/existing Investments in an infrastructure must occur at multiple levels
improvement projects 32 of the health care organization. At the patient care level, organiza-
CUSP step 4 Learn from defects using structured tool 40 tions will likely need to increase nursing hours per patient day to
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CUSP step 5 Implement tools to improve teamwork, communication, culture (eg, daily goals ) accommodate the myriad of new work to improve and document
patient safety. Just one example of new work is medication recon-
ciliation, which was first addressed by The Joint Commission as
a 2006 National Patient Safety Goal and is now mandated for all
support from senior leaders in the health care organization to provide patients at hospital admission, transfer between units, and hospital
assistance in garnering resources. discharge. This requires the reconciliation of existing and newly
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The CUSP model provides a knowledge base about the science of written medication orders to ensure that patients receive appropriate
safety so frontline staff can recognize safety hazards in the workplace pharmacologic therapies. This adds significant new work for nurses
and design interventions to eliminate these hazards. Moreover, it and is generally not accompanied by an increase in nursing hours per
emphasizes the importance of effective teams, trains staff to use a patient day—a common measure of nursing resources—or dedicated
practical tool to investigate and learn from defects, and offers tools time for physician oversight. Each new intervention may provide
to improve teamwork and communication both within and between some benefit to patients, but there must be resources to support
patient care areas. Implemented initially in two surgical intensive care the new work.
units at The Johns Hopkins Hospital in 2001, the program produced At the unit level, there should be a nurse safety manager with
a significant reduction in ICU length of stay and medication errors as training in the science of safety who can carry through this training
well as a potential improvement in nurse turnover. 33,36,37 to unit staff. There should be a CUSP team or a similar infrastructure
While CUSP provides a platform for individual staff to share expe- to develop, implement, and monitor safety projects. Finally, nurse
riences with everyone in the unit and empowers the group to solve managers should be equipped with dedicated time and support to
local problems in care delivery, embedding these interventions in proactively identify and mitigate hazards on their units.
the daily work routine can also enforce positive changes in the unit’s At a departmental or hospital level, there should be a patient safety
safety culture. For example, creating interdisciplinary rounds in the director with higher level training and an understanding of both the
unit offers a platform for nurses to voice concerns, seek clarification technical aspects and the leadership aspects of improving patient
about a patient’s management, and gain autonomy as the bedside safety. The role of the patient safety officer/director is to design and
caregiver. Interdisciplinary rounds lessen the hierarchy that usually lead activities that include the following:
occurs between physicians and nurses, a hierarchy that causes ineffec- • Identify hazards (typically through an incident reporting system)
tive collaboration among clinical disciplines and prevents individuals • Conduct root cause analyses and implement the recommendations
from acting upon safety concerns. Implementation of a daily goals • Develop measures of patient safety, then monitor and report prog-
sheet (Fig. 5-2) can also help improve communication and collabora- ress back to clinicians
tion among nurses and physicians for individual patients, plus leads • Design, implement, and evaluate new interventions
to more effective coordination of daily care plans and efficient move- • Comply with the ever-growing list of regulatory and accreditation
ments of patients to discharge. 38 requirements
C. Learning from defects: Retrospective identification of medical • Educate clinicians regarding safety efforts
errors and in-depth analysis of contributing factors provides an • Monitor and improve safety culture
opportunity to learn from, rather than just recover from harm. E. Reducing diagnostic errors: Errors in diagnosis are also an impor-
Knowledge is a better defense against the recurrence of the same tant source of preventable harm. While grossly underreported, an
or a similar harm and is essential to promoting a culture of safety. estimated 40,000 to 80,000 deaths occur annually among hospitalized
The Institute of Medicine has targeted incident reporting systems as patients in the United States because of a misdiagnosis. Such errors
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a method to collect defect information, investigate the causes, and include diagnoses that were missed, wrong, or delayed, as detected
improve safety. To make incident data useful, health care organiza- by subsequent definitive tests or findings. Harm may result from
1,39
tions can learn from reported mistakes through formal (root cause delay or failure to treat the correct underlying disease, complications
analysis) or informal (case review) methods. of unnecessary diagnostic testing, or treating a condition that is not
Pronovost and colleagues developed a practical tool to investigate actually present.
and learn from defects in patient care. The Learning From Defects Patients in an intensive care unit are especially prone to suffering
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tool is a “lighter” version of a root cause analysis and provides a struc- harm from diagnostic errors. They have limited reserve, often require
tured approach to help caregivers and administrators investigate a fast diagnosis and treatment, are cared for by multiple clinicians, and
case and identify systems that contributed to the defect (Table 5-2). It undergo frequent laboratory and imaging evaluations. In a recent
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also provides a follow-up mechanism to ensure safety improvements systematic review examining autopsy-confirmed diagnostic errors in
are achieved. Use of the tool allows staff to investigate more incidents adult ICU patients, 28% had at least one misdiagnosis; of the autopsies
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closer to the time of the incident and to identify and mitigate a larger reporting misdiagnosis error classifications, 8% were major and poten-
number of contributory factors. The learning from defects process tially lethal with an additional 15% considered major but not lethal.
can be implemented as part of the CUSP framework or as a key ele- Extrapolating to all ICU deaths annually, this suggests that 34,000 (95%
ment in educational programs focusing on quality improvement. 41 CI = 22,600 to 40,500) ICU patients in the United States may die as
D. Investing in safety infrastructure: Fulfilling a commitment to safe and the direct result of diagnostic errors each year, a number comparable to
high-quality care will not be possible without substantial investment estimated deaths from catheter-related bloodstream infections. 46

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