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THE ROLE OF INFORMATICS IN PATIENT SAEFETY - AN OVERVIEW

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THE ROLE OF INFORMATICS IN PATIENT SAEFETY - AN OVERVIEW

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WHAT IS A CULTURE OF SAFETY?                       

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WHAT IS A CULTURE OF SAFETY?                       

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The American Nurses Association (ANA) defines a Culture of Safety as a work culture in which healthcare providers at all levels of the organization understand that they have an ethical duty to ensure patient safety and are committed to core values and behaviors that emphasize safety over competing goals (Sorrell, 2017).  Ethical issues related to medical errors can be categorized around four ethical principles:

1. autonomy and right to self-determination;

2. beneficence and nonmaleficence;

3. disclosure and right to knowledge; and

4. veracity.

Not having a culture of safety contributes to health care errors, which include workplace safety, healthcare acquired infections, and medical errors,  that are detrimental to patients' outcomes:

*How do you know if you’re working in a culture of safety? In this video, Dr. David W. Bates, a world-renowned leader in patient safety, defines a culture of safety and gives advice to organizations that are hoping to strengthen their safety culture.

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Joint Commission Center for Transforming Healthcare

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KEY FEATURES OF A CULTURE OF SAFETY                                   •	Supportive collaboration between nurses, physicians and the interdisciplinary teams to seek solutions to patient safety issues.                          •	Positive approach to reporting medication errors, and near misses, without the fear of being terminated or reprimanded.                          •	Incentives and recognition for health care professionals who report errors, near misses, unsafe behaviors, and conditions that put patients at risk, all which drive improvement. •	Acknowledgement of the high-risk issues of a health organization and implementing initiatives to improve hand hygiene, falls, medication errors, and all kinds of outcomes.  •	Building relationships and establishing trust between patients and the staff within a healthcare organization. 

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KEY FEATURES OF A CULTURE OF SAFETY                                   •	Supportive collaboration between nurses, physicians and the interdisciplinary teams to seek solutions to patient safety issues.                          •	Positive approach to reporting medication errors, and near misses, without the fear of being terminated or reprimanded.                          •	Incentives and recognition for health care professionals who report errors, near misses, unsafe behaviors, and conditions that put patients at risk, all which drive improvement. •	Acknowledgement of the high-risk issues of a health organization and implementing initiatives to improve hand hygiene, falls, medication errors, and all kinds of outcomes.  •	Building relationships and establishing trust between patients and the staff within a healthcare organization. 

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*This video shows a fictional scenario in which a positive culture of safety overcomes multiple commonly seen barriers to infection prevention in dialysis facilities. Practicing hand hygiene, , wearing protective equipment, and following a checklist are just three important ways you can foster a culture of safety. See how these techniques, which can reduce adverse outcomes like central line-associated blood stream infections (CLABSIs), are put into action.

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STRATEGY CHECKLIST FOR DEVELOPING A CULTURE OF SAFETY IN YOUR WORKPLACE

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STRATEGY CHECKLIST FOR DEVELOPING A CULTURE OF SAFETY IN YOUR WORKPLACE

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ROLE OF HUMAN FACTORS ENGINEERING IN A JUST CULTURE

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ROLE OF HUMAN FACTORS ENGINEERING IN A JUST CULTURE

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Use a systems engineering approach where manufacturers partner with organizations to identify patient safety risks and promote safe technology integration.

Human factors engineering applies what is known about human capabilities and limitations to the design of products, processes, systems, and work environments to reduce operational errors, operator stress, training requirements, user fatigue and product liability.

*This video, Annie's story, shows how healthcare organizations seeking high reliability should embrace a just culture in all they do. This includes human factors engineering using a system's approach to analyzing near misses and harm events.

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Annie's Story: How A System's Approach Can Change Safety Culture

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25 SIGNS YOU HAVE AN AWESOME SAFETY CULTURE

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25 SIGNS YOU HAVE AN AWESOME SAFETY CULTURE

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According to OSHA, "Safety cultures consist of shared beliefs, practices, and attitudes that exist at an establishment. Culture is the atmosphere created by those beliefs, attitudes, etc., which shape our behavior."

By definition, safety culture is difficult to measure. How do you measure values, attitudes and beliefs?

Following are 25 ways to tell whether or not you have an awesome safety culture. If you can answer yes to most of these, you're doing great. Keep it up!

If not, you have some work to do. Don't be discouraged, culture change takes time and perseverance.

1. There is visible leadership commitment at all levels of the organization.

Leadership commitment (or lack thereof) to safety will always show. What your organization's leaders value is typically what gets done. In great safety cultures, leadership proves their commitment to safety through their actions and how they empower others throughout the organization to win with their safety initiatives.

2. All employees throughout the organization exhibit a working knowledge of health and safety topics.

When you value something, it's worth the time and energy it takes you to excel at it. In great safety cultures, all employees throughout the organization have invested in a working knowledge of health and safety topics. In order words - they're competent in safety. They know their roles and responsibilities. They know their stuff.

3. There is a clear definition of the desired culture the organization wishes to achieve.

How do you create movement toward the safety culture your organization wishes to achieve? You set a goal. You write it down. You measure where you're at. You develop a plan to make it happen. It's a simple strategy, yes, but not simplistic. Make sure you develop a plan that includes a clear definition of what your desired safety culture looks and feels like.

4. There is a lack of competing priorities - safety comes in first every time!

Who wins the showdown between production and safety at your organization? Does safety win every time or only when it's the easy and convenient option? Safety needs to win every time or you've developed a toxic culture. It's that simple.

5. There is visible evidence of a financial investment in health and safety.

Safety slogans are great, but creating a winning safety culture requires resources. Improvements need to be made. Problems need to be solved. If funding a safety project is a constant battle and there is no evidence of a financial investment in safety, you may have a safety culture issue.

6. Opportunities for improvement are identified and resolved before a problem occurs.

Proactive organizations identify issues before they become costly problems and injuries. Are you passively reacting to every injury? Or are you proactively finding risk factors and putting control measures in place? Safety leaders that are ahead of the curve identify and resolve issues before a more serious problem occurs down the road.

7. There is regular, facility-wide communication on health and safety topics.

Communication, communication, communication. An internal safety communication process increases awareness of safety topics and transfers knowledge to empower your people to be successful.

8. A fair and just discipline system is in place for all employees.

We live in a sowing and reaping world. There are your actions and there are the consequences. Instituting a fair and just discipline system for safety behaviors is a necessary step to follow through on your claim that safety is important to you.

9. There is meaningful involvement in health and safety from everyone in the organization.

Safety is everyone's job, and everyone needs to do their job well. From the facility manager to the safety manager to the supervisor to the worker on the floor, it takes a team effort to win at safety. Everyone needs to play a meaningful role in the safety process.

10. Managers spend an adequate amount of time out on the shop floor, where the people are.

Great safety leaders spend time out where the people are. It's where the real work gets done - the shop floor. That's where you can find problems. It's where you can talk to operators and get their feedback. It's where you'll be seen (and respected) as the safety leader. You have administrative duties, yes. But the great ones get out there and get their hands dirty.

11. Participation rates are at an all-time high, indicating that employees are highly motivated and your marketing of health and safety initiatives is effective.

Safety success tends to breed more success. Safety culture is the vehicle that drives this phenomenon. When participation rates are at an all-time high, you've been able to build buzz and positive momentum for your future efforts. Keep it going.

12. Employees are actively engaged in health and safety initiatives, producing tangible results for your company.

Are your employees engaged in health and safety initiatives? Or are they dismissive, leaving you wondering if you're getting through at all? Engaged employees are more productive, giving you tangible results and feedback.

13. Your employees report high job satisfaction due to the company's commitment to their health and well-being.

Employee retention and engagement is a focus point for organizations around the world, and rightfully so. With the skills and talent gap growing wider and wider as Baby Boomers retire, engaging your workforce through excellence in health and safety builds culture. Do this right and you'll find yourself with highly satisfied employees and the safety culture you were striving toward.

14. Safety is the first item on the agenda of every meeting.

Is safety at the top of your agenda sheet? I hope so. If not, I bet I can guess what the safety culture is like at your organization. Either put safety first or send a loud and clear message to everyone at the meeting that you don't truly care.

15. Employees feel comfortable reporting safety issues to their supervisors.

Do your employees feel comfortable reporting a safety issue to supervisors? Or do they feel like they will be ignored or (even worse) punished for coming forward? This is a huge indication of the culture you're molding. Employees should feel encouraged and met with praise when they report safety issues.

16. Regular, detailed audits of the company's health and safety program are conducted by an external auditor.

Great safety leaders are confident enough to be audited by an external auditor. It's one thing to do an internal audit (and pat yourself on the back). It's another thing to bring in an outsider to do an external audit (and meet the challenge head on).

17. Rewards and recognition of good behaviors are regularly given and serve to motivate continued health and safety performance.

Positive safety behaviors should be awarded and these awards should motivate continued health and safety performance. You know what employees value but don't get nearly enough? Recognition of a job well done. Recognize and reward positive behaviors. The word will get out.

18. Safety is a condition of employment.

Can you really afford an employee who thinks they are above the rules when it comes to safety? Lives are on the line. Safety should be a condition of employment. If your organization values safety above all else, you make safety a fundamental value. Any employee who doesn't share this value should be asked to leave and go work somewhere else.

19. Managers and supervisors respond positively to safety issues that are raised.

Good managers and supervisors understand that when employees raise a safety issue, it's another opportunity for improvement. This opportunity mindset allows them to respond positively to the employee that raised the issue and escalate the issue far enough to get a solution put in place.

20. Safety is viewed as an investment, not a cost.

Companies that perform well in safety also perform well in business. Knowing the true value of safety, organizations with a great safety culture view safety as an investment, not a costly and dreaded expenditure.

21. A high standard exists for accurate and detailed reporting of injuries and illnesses - nothing is swept under the rug!

This is a big one. Nothing should be swept under the rug. In great safety cultures, transparency and integrity is the only way to conduct business. This is about living in reality and confronting the challenges that exist in your workplace.

22. There is a concrete definition of what success looks like for your health and safety program.

How will you know when you've achieved your goals? You'll know because you have set measureable goals and you know exactly what success looks like.

23. The organization has the willpower to make major changes when necessary.

Quick fixes and easy solutions are great. But your organization's willpower will be tested when you need to make a major move. In great safety cultures, good intentions are backed by the willpower to endure major changes, expensive investments and hard decisions.

24. Safety issues are dealt with in a timely and efficient manner.

A functioning safety process deals with issues in a timely and efficient manner. Hazards are identified and controls are put in place within a reasonable time period. Knowing injury risks exist and not doing anything about them is a sure sign the organization has become complacent and culture is rapidly deteriorating.

25. All employees throughout the organization are empowered with the necessary resources and authority to find and fix problems as they see them.

Your safety process should have clearly defined roles and responsibilities. In order for the people throughout your organization to successfully accomplish their role in the process, they will need resources and authority to make decisions.

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25 Signs You Have An Awesome Safety Culture

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According to OSHA, "Safety cultures consist of shared beliefs, practices, and attitudes that exist at an establishment. Culture is the atmosphere created by those beliefs, attitudes, etc., which shape our behavior." By definition, safety culture is difficult to measure. How do you measure values, attitudes and beliefs?

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(McGonigle & Mastrian, 2018, p. 298)

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STRATEGIES FOR DEVELOPING A SAFETY CULTURE                                 •	Teamwork training            •	Unit-based safety teams, councils or committees                                       •	Appointing a Safety Champion for every unit          •	Creating an adverse event response team            •	Surveys and action plans                                          •      Debriefing, re-enacting or simulating adverse events to understand the process that failed                                •	Executive walk-arounds: Executives visiting patient care areas to engage patients, nurses, and providers and discuss patient safety concerns.      •	Blame-free reporting environment that encourages easy-to-use blame-free or anonymous error reporting forms                                         •	Enhancing patient safety during hand-offs: standardized communication and teamwork using the ‘SBAR’ method.         

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STRATEGIES FOR DEVELOPING A SAFETY CULTURE                                 •	Teamwork training            •	Unit-based safety teams, councils or committees                                       •	Appointing a Safety Champion for every unit          •	Creating an adverse event response team            •	Surveys and action plans                                          •      Debriefing, re-enacting or simulating adverse events to understand the process that failed                                •	Executive walk-arounds: Executives visiting patient care areas to engage patients, nurses, and providers and discuss patient safety concerns.      •	Blame-free reporting environment that encourages easy-to-use blame-free or anonymous error reporting forms                                         •	Enhancing patient safety during hand-offs: standardized communication and teamwork using the ‘SBAR’ method.         

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*This video shows that Steve Barker, Chief Science Officer of Masimo Corporation, regards errors in hand-off communications as some of the most detrimental in patient care.

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Recent Thoughts on Hand-off Communications

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TECHNOLOGY TO PREVENT MEDICATION ERRORS:

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TECHNOLOGY TO PREVENT MEDICATION ERRORS:

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Studies show that computerized setups can help reduce Med errors by 85%.

Medication errors happen during 3.8 million hospital admissions and

3.3 million outpatient visits every year in the US.

An estimated 7000 of those incidences result in fatalities.

Mistakes often happen when providers fail to use what is known as "The Five Rights of Medication Administration".

1. Right Patient

2. Right Medication

3. Right Time

4. Right Dose

5. Right Route

TECHNOLOGIES THAT SUPPORT CORRECT MEDICATION ADMINISTRATION:

1. Smart Pumps

2. Automated dispensing

3. Barcoding of medication

4. Eletronic medication reconciliation

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MOST FREQUENT SAFETY ISSUES (National Patient Safety Foundation, 2016)

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MOST FREQUENT SAFETY ISSUES (National Patient Safety Foundation, 2016)

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Wrong-site surgery

Hospital-acquired infections

Falls

Hospital Readmissions

Diagnostic errors

Medication errors

- More than 250,000 preventable patient deaths may happen each year in U.S. hospitals alone (Sorrell, 2017)           - Up to one-third of patients are unintentionally harmed during a hospital stay (James, 2013)             - Preventable medical harm ranks as the 3rd leading cause of death in the U.S. (Makary & Daniel, 2016)
*Video: Every mistake has a face, every error is a person.

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STRATEGY EXAMPLE: HOSPITAL SAFETY VIDEO 

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STRATEGY EXAMPLE: HOSPITAL SAFETY VIDEO 

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a great strategy to educate and empower patients about safety upon admission.

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Patient safety briefing for NHS patients

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THOUGHT-PROVOKING QUESTIONS: *CHOOSE 2 & EXPLAIN YOUR ANSWERS 

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THOUGHT-PROVOKING QUESTIONS: *CHOOSE 2 & EXPLAIN YOUR ANSWERS 

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1. What do you see as the biggest challenge to further improve both safety performance and culture?

2. What do you see as the most important safety roles and responsibilities for someone in your position?

3. Would you or your family feel safe to be a patient (having surgery, a colonoscopy, hip/knee replacement, give birth, cancer treatments, dialysis, Emergency Room visit for heart attack, stroke, MVA or pediatric emergency) at your local hospital? Explain

4. What Patient Safety issues/ procedures could your workplace or local hospital improve on?

5. What are some examples of workarounds, or shortcuts that you have witnessed in the clinical setting? Did use of the workaround outweigh the risk? What are your thoughts on the matter?

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Published on Learn what is critical to creating a culture of safety in your organization. These 7 keys based on the science of behavior analysis and positive reinforcement will provide the foundation for a sustainable, effective safety system. 1. 7 Keys for Creating a Safety Culture By Judy Agnew Senior Vice President, Safety Solutions 2.

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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Wearable Devices:

These devices help remove the risk of human error. They allow for faster record keeping and allow consistent monitoring of the patient’s status. An example is the “Steth IO Smartphone Stethoscope.” This app allows healthcare workers to use their smartphone to get breath sounds and see heart rates. This is especially beneficial in the pediatric population as a smartphone is less intimidating. It also gives these healthcare workers the access to a full range of information and tracking of medical needs.

Airmail:

Airmail is a system used in some hospitals that allow nurses to send a short text page to a physician. This is beneficial as it gives the provider an idea of what you’re needing in case they are unable to return a phone page.

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EKG on Your Wrist: Will Wearable Devices Change Healthcare? | THE BIG IDEA

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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Electronic Medical Records:

EMRs are replacing outdated paper records. Nurses and technicians are responsible for inputting patient data into a central, digitized system. Medical billers and coders appointments update patient records with diagnostic codes (such as test results) and submit medical claims to insurance companies. EMRs lead to greater patient care by automatically alerting if the patient has a certain allergy or intolerance to a certain medication. This is not only beneficial to health care workers, but medical billers now have the ease of entering data into a computerized system which is much less time consuming and reduces the risk of errors in patient data or financial details. “According to a study from the University of Michigan, shifting from paper to electronic health records reduced the cost of outpatient care by 3%. These researchers estimated this as $5.14 in savings per patient each month. In a large city hospital network, that amount is incalculable.” (Banova 2019)

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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Telemedicine:

Telemedicine is a two-way video consultation. It allows patients to be diagnosed without leaving their home.

Telemedicine helps patients to have shorter wait times, access to healthcare in rural areas, and improved efficiency of patient care.

It also enhances patient engagement and satisfaction by making it easier for patients to stay healthy and involved in their healthcare.

It is proven that patients love the convenience, flexibility, and real-time care with their providers.

*Video: With a lack of mental health providers, telehealth technology is improving access to care for those needing a psychiatric evaluation, reducing cost and providing more efficient care to patients. At Advocate Christ Medical Center, in Oak Lawn, Ill, telehealth technology helped reduce the wait times in the emergency department for behavioral health patients by 33 percent.

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(McGonigle & Mastrian, 2018, p. 316)

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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EXAMPLES OF TECHNOLOGY FOR PATIENT SAFETY

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Portable Monitors:

Portable monitors have many benefits. They allow nurses to check up/ monitor patients even if they are on the move by monitoring ECG, respirations, heart rate, and oxygen saturations or when they are at risk for falls or being unsafe. This helps patients to constantly be monitored from anywhere in the hospital and alerts/ alarms can be sent to nurses.

Example 1 Video:

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Actively listen and be your patient's strongest advocate!

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Actively listen and be your patient's strongest advocate!

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Alicia Cole's Patient Story: 5 Years Later

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JU-NUR 353- Collaborative Team Agreement - Charter

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INFORMATICS TECHNOLOGY FOR PATIENT SAFETY

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INFORMATICS TECHNOLOGY FOR PATIENT SAFETY

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Benefits:

improves communication between clinicians

Reduces human errors and adverse events

knowledge more accessible to clinicians

Provides feedback

Tracks performance

provides access to information

increases patient-centered care

Electronic Medical Records

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Patient Safety Success Story: CHOC Children's Hospital

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Example 2 Video:

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Philips IntelliVue Guardian automated Early Warning Scoring System, Won Product Leadership Award