clark safety in hc monday 13 30

8/13/2019 Clark Safety in HC Monday 13 30

1/34

C U R S O E O F I C I N A D E T R A B A L H O S O B R E G E R E N C I A M E N T O D E R I S C O E S E G U R

C U R S O E O F I C I N

A D E T R A B A L H O S O B R E G E R E N C I A M E N T O D E R I S C O E S E G U R A N A N A E M S A

A E M S A D E D E

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5

7 ,

2 0 0 7

Safety in HealthcareSafety in Healthcare

Tobey Clark, MSEE, CCETobey Clark, MSEE, CCE

University of VermontUniversity of VermontUSA USA

Acknowledgment to many ACCE faculty and Andrei Issakov, WHO Acknowledgment to many ACCE faculty and Andrei Issakov, WHO


2/34

A d v a n c e

d C l i n i c a l

E n g

i n e e r

i n g

W o r

k s h o p

- H e a

l t h c a r e

R i s k M a n a g e m e n t a n

d S a f e t y

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7 ,

2 0 0 7

Agenda Agenda Hour 1Hour 1

Safety in healthcare overviewSafety in healthcare overview

Patient safetyPatient safetyMedical deviceMedical device

Safety issuesSafety issues International improvement effortsInternational improvement efforts U.S. improvement effortsU.S. improvement efforts


3/34

A d v a n c e

d C l i n i c a l

E n g

i n e e r

i n g

W o r

k s h o p

- H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7

How hazardous is health care?How hazardous is health care?

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Total lives lost per year

N u

m b e r o

f e n c o u n

t e r s

f o r e a c

h f a t a l i t y

DangerousDangerous(>1/1000)(>1/1000)

UltraUltra --safesafe(


4/34

A d v a n c e

d C l i n i c a l

E n g

i n e e r

i n g

W o r

k s h o p

- H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7

Institute for Medicine Report:Institute for Medicine Report:To err is human: building a safer health system To err is human: building a safer health system

44,00044,000 --98,000 die98,000 dieeach year due toeach year due tomedical errorsmedical errors Failure to perform aFailure to perform a

desired act ordesired act or rightrightaction action

Errors will always occurErrors will always occur-- goal is to reduce thegoal is to reduce thenegative outcomesnegative outcomes

Mostly medicationMostly medicationerrorserrorsMore than 2/3rds dueMore than 2/3rds duetoto human errorhuman error


5/34

A d v a n c e

d C l i n i c a l

E n g

i n e e r

i n g

W o r

k s h o p

- H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5

7 ,

2 0 0 7

Why are errorsWhy are errorsprevalent in healthprevalent in health

care?care?Most complex systemMost complex system

One of most hazardous activitiesOne of most hazardous activitiesLagging behind other highLagging behind other high --riskrisk

industriesindustriesFraught with obstacles to changeFraught with obstacles to change


6/34

A d v a n c e

d C l i n i c a l

E n g i n e e r

i n g

W o r

k s h o p -

H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5

7 ,

2 0 0 7

Human beings make mistakesHuman beings make mistakesbecause the systems, tasks andbecause the systems, tasks and

processes they work in areprocesses they work in are

poorly designedpoorly designed

Dr LucianDr Lucian Leape Leape , testifying to the Presidents , testifying to the Presidents Commission on Consumer Protection andCommission on Consumer Protection and

Quality in Health Quality in Health


7/34

A d v a n c e

d C l i n i c a l

E n g i n e e r i n g

W o r

k s h o p -

H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a

z i l

N o v .

5

7 ,

2 0 0 7

Adverse Event vs. Adverse Event vs.

Error Error ErrorError definition bears upon concept ofdefinition bears upon concept ofpreventability, and is therefore processpreventability, and is therefore process --focusedfocused

Adverse event Adverse event describes harm to the patient,describes harm to the patient,and is thus outcome focusedand is thus outcome focused

Relationship between errors and adverse events:Relationship between errors and adverse events:

Errors Adverse

Events


8/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Why Do Adverse EventsWhy Do Adverse Events

Occur?Occur? UseUse errorerror

EquipmentEquipmentfailure/manufacturingfailure/manufacturingdefectdefect

Environmental factorsEnvironmental factors

Poor designPoor design

Patient factorsPatient factors

SystemSystem failurefailure

CombinationsCombinations


9/34


10/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

An International An International

ProblemProblem

UK UK around 10% of admissions or at a ratearound 10% of admissions or at a rateof 850,000 adverse events a yearof 850,000 adverse events a year Australia 250,000 adverse events Australia 250,000 adverse events

50,000 permanent disability50,000 permanent disability10,000 deaths10,000 deaths

N.Z. confirmed 10% of admissionsN.Z. confirmed 10% of admissionsDenmark confirmed 9% of admissionsDenmark confirmed 9% of admissionsEUEU every tenth patientevery tenth patient


11/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Adverse Events in Acute Hospitals Adverse Events in Acute Hospitals

11% of adverse events are due to badmanufacturing of medical devices

11% of adverse events are due to badmanufacturing of medical devices Adverse event rate (percentage)

0

2

4

6

8

10

12

14

16

18

New York Australia Utah and

Colorado

London New

Zealand

Canada DenmarkNew York Australia Utah and

ColoradoLondon New

ZealandCanada Denmark

National Patient Safety AgencyJuly 2005


12/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

What does it cost?What does it cost?

High toll in financial loss as wellHigh toll in financial loss as well

UK UK 2 billion a year in additional hospital stays;2 billion a year in additional hospital stays;400 million annually in paid litigation claims400 million annually in paid litigation claimsplus potential liability ofplus potential liability of 2.4 billion in existing2.4 billion in existing

and expected claims;and expected claims;

HAIHAI -- 15% of which avoidable15% of which avoidable -- 1 billion1 billioneveryevery yearyearUSA USA

$17$17 --29 billion annually in lost income,29 billion annually in lost income,disability and additional medical expensesdisability and additional medical expenses


13/34

y


14/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R

i s k M a n a g e m e n t a n

d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7 International collaboration toInternational collaboration to

accelerate improvementsaccelerate improvementsFocus on systemsFocus on systemsImprove detection andImprove detection and

understanding of safetyunderstanding of safetyproblemsproblems

Build and spread knowledgeBuild and spread knowledge

base of interventionsbase of interventions Action on topics which address Action on topics which addresssignificant risk significant risk

Support regional and countrySupport regional and countryprogrammesprogrammes

y


15/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R


d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

BUILDING SAFE ENVIRONMENTFOR SAFER CARE

Global Patient Safety ChallengeClean Care is Safer Care, 2005-2006Safe Environment for Safer Care, 2007-2008

Patients for Patient SafetyPatients for Patient Safety

Research for Patient SafetyResearch for Patient Safety

Patient Safety SolutionsPatient Safety Solutions

Reporting and Learning SystemsReporting and Learning Systems

Patient Safety TaxonomyPatient Safety Taxonomy

y


16/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R


d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Needs analysis &strategic planning Needs analysis &Needs analysis &

strategic planning strategic planning

S a

f

e t y

HTA (macro & micro)

HTA HTA (macro & micro) (macro & micro)

Pre-purchase evaluation

Pre Pre - - purchase purchase evaluation evaluation

Selection & procurement

Selection &Selection & procurement procurement

User & servicetraining

User & serviceUser & servicetraining training

Risk management &quality assurance

Risk management &Risk management &quality assurance quality assurance

CE/HE management& monitoring

CE/HE managementCE/HE management& monitoring & monitoring

Operation, service &maintenance

Operation, service &Operation, service &maintenance maintenance

Acceptance &installation

Acceptance & Acceptance &

installation installation

HealthcareTechnologyManagementSpectrum

HealthcareHealthcareTechnologyTechnologyManagementManagement

SpectrumSpectrum

ty


17/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R

i s k M a n a g e m e n

t a n

d S a f e t y

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

WHO Medical DeviceWHO Medical DeviceSafety EffortsSafety Efforts

Development of national policy:Development of national policy: tools to assess and strengthen nationaltools to assess and strengthen national

regulatory authoritiesregulatory authoritiesQuality and safety:Quality and safety: elaboration of new ISO standardselaboration of new ISO standards

Access: Access: WHO Essential Healthcare Technology PackageWHO Essential Healthcare Technology Package

Appropriate use of equipment in order to Appropriate use of equipment in order toreduce risks:reduce risks: diffusion of materialsdiffusion of materials

t y


18/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R

i s k M a n a g e m e n

t a n

d S a f e ty

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

U. S. Patient SafetyU. S. Patient SafetyMovement OriginMovement Origin

Meeting of 300 experts held in 1996 in theMeeting of 300 experts held in 1996 in the

Annenberg Conference Center near Palm Annenberg Conference Center near PalmSprings, CA.Springs, CA.

in response to several errorin response to several error --induced sentinelinduced sentinelevents in the midevents in the mid --1990s that captured the1990s that captured theattention of the public media.attention of the public media.

American Medical Association American Medical Association American Association for the Advancement of Science American Association for the Advancement of Science Veterans Administration Veterans AdministrationJoint CommissionJoint Commission

t y


19/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R


d S a f e ty

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Joint Commission:Joint Commission:

Accreditation Organization Accreditation Organization Accreditation guidelines sets quality standards for all Accreditation guidelines sets quality standards for allareas including healthcare technologyareas including healthcare technology

Accreditation means hospitals will receive payment for federally Accreditation means hospitals will receive payment for federallycovered patientscovered patients

Use in US hospitals and now internationallyUse in US hospitals and now internationally

Survey processSurvey process Interviews, onInterviews, on --site observation ofsite observation ofpatient care process, policies, procedures and otherpatient care process, policies, procedures and otherdocuments, and results of self documents, and results of self --assessmentassessment

Accreditation Decision Process Accreditation Decision Process-- Each standard is scoredEach standard is scored fully met,fully met, partiallypartially

met,met, oror not met.not met.

ThreeThree -- ear accreditationyear accreditation

t y


20/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R


d S a f e t

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Joint CommissionJoint Commission

Patient Safety StandardsPatient Safety Standards Annual FMEA (Failure Mode Annual FMEA (Failure Mode

and Effect Analysis)and Effect Analysis) Sentinel EventsSentinel Events RCA (RootRCA (Root

Cause Analysis)Cause Analysis) National Patient Safety GoalsNational Patient Safety Goals

t y


21/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e R


d S a f e t

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Joint CommissionJoint Commission

International Center for Patient SafetyInternational Center for Patient Safety http://www.jcipatientsafety.org/http://www.jcipatientsafety.org/StandardsStandardsSpeakSpeak UpTMUpTM programsprogramsSystem design and redesign, productSystem design and redesign, productsafety, safety of services, andsafety, safety of services, andenvironment of care,environment of care,

t y
http://www.jcipatientsafety.org/http://www.jcipatientsafety.org/http://www.jcipatientsafety.org/


22/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

Medical Device ErrorsMedical Device Errors(from Shepard)(from Shepard)

Estimated at about 1Estimated at about 1 --2% of total in2% of total inIOM report or less than 1000/yearIOM report or less than 1000/year

5050 --70% human error70% human error Devices, external, patient & deliberateDevices, external, patient & deliberate

DevicesDevices Ventilator, transfusion, infusion, defibrillator, Ventilator, transfusion, infusion, defibrillator,utility systems,utility systems, electrosurgeryelectrosurgery ,, trocarstrocars &&

anesthesia unitsanesthesia unitsOperating room & EROperating room & ER -- Home! Home!


23/34

fe t y


24/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

What Medical Devices Are MostWhat Medical Devices Are Most

Commonly Associated with Events? Commonly Associated with Events? Top 10 Medical DevicesTop 10 Medical Devices

1.1. Infusion PumpInfusion Pump wrong dose, infiltration, freewrong dose, infiltration, freeflowflow

2.2. Ventilators and Anesthesia systems Ventilators and Anesthesia systems breathingbreathingcircuit leaks, disconnections, failure to detectcircuit leaks, disconnections, failure to detectalarmalarm

3.3. Patient monitorsPatient monitors improper settings, alarmsimproper settings, alarms

4.4. DefibrillatorsDefibrillators lack of familiarity with deviceslack of familiarity with devices

5.5. Electrosurgical units and lasersElectrosurgical units and lasers fires due tofires due toexcessive oxygen and improper preparationsexcessive oxygen and improper preparationsproceduresprocedures

6.6. HeartHeart --lung bypass unitslung bypass units failure to detect leaksfailure to detect leaks

fe t y


25/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

What Medical Devices Are MostWhat Medical Devices Are Most

Commonly Associated with Events?Commonly Associated with Events?Top 10 Medical DevicesTop 10 Medical Devices

(continued(continued

):):

7. Catheters and7. Catheters and needlestick needlestick prevention devicesprevention devices shearing duringshearing duringinsertion of catheter, and failure toinsertion of catheter, and failure touseuse needlestick needlestick prevention devicesprevention devices

8.8. TrocarsTrocars and staplersand staplers improperimproperuseuse

9.9. EndoscopyEndoscopy equipmentequipment issues ofissues ofcontamination during endoscopecontamination during endoscopecleaningcleaning

10. MRI10. MRI ferrous metal objectsferrous metal objectsentering MRI suiteentering MRI suite

fe t y


26/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f e

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5

7 ,

2 0 0 7

U. S. National OrganizationsU. S. National OrganizationsFocused on SafetyFocused on Safety

Food and Drug AdministrationFood and Drug Administration Center for Devices and RadiologicalCenter for Devices and Radiological

HealthHealth http://www.fda.gov/cdrh/http://www.fda.gov/cdrh/

Device approvalDevice approvalRecallsRecalls Example Alert:Example Alert: More Patient DeathsMore Patient Deaths

fromfrom Luer Luer Misconnections Misconnections Design ofDesign of luerluer connectors makes it easyconnectors makes it easyfor unrelated delivery systems to befor unrelated delivery systems to be

connected to each other, sometimes withconnected to each other, sometimes withdisastrous resultsdisastrous results

f e t y
http://www.fda.gov/cdrh/http://www.fda.gov/cdrh/http://www.fda.gov/cdrh/


27/34

A d v a n c e

d C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5 7

, 2 0 0 7


FDA FDA Video Video webcastwebcastMisconnectionsMisconnections

f e t y
http://seg5.mpeg/http://seg5.mpeg/http://seg5.mpeg/


28/34

A d v a n c e d

C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f

S a o

P a u

l o -

S P , B r a z

i l

N o v .

5 7

, 2 0 0 7


MEDSUNMEDSUN Pilot program for FDA Pilot program for FDA Adverse event reporting Adverse event reportinghttp://http:// www.medsun.netwww.medsun.net

Occupational Health and SafetyOccupational Health and Safety Administration Administration

Health Facility WorkersHealth Facility Workershttp://www.osha.gov/SLTC/healthcarefacilities/index.htmlhttp://www.osha.gov/SLTC/healthcarefacilities/index.html

f e t y
http://www.osha.gov/SLTC/healthcarefacilities/index.htmlhttp://www.osha.gov/SLTC/healthcarefacilities/index.htmlhttp://www.osha.gov/SLTC/healthcarefacilities/index.html


29/34

A d v a n c e d

C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a f

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7


ECRI InstituteECRI Institute www.ecri.orgwww.ecri.orgFree Medical Device Safety ResourcesFree Medical Device Safety Resources Safety Precautions in the MR EnvironmentSafety Precautions in the MR Environment Improper Use of Helical Tacks Can HarmImproper Use of Helical Tacks Can Harm

PatientsPatients Sharps Safety andSharps Safety and Needlestick Needlestick PreventionPrevention

Bed Rail SafetyBed Rail Safety White Paper: Event ReportingWhite Paper: Event Reporting Proactive Hazard Analysis and Health Care PolicyProactive Hazard Analysis and Health Care Policy BariatricsBariatrics Risk AssessmentRisk Assessment
http://www.ecri.org/http://www.ecri.org/http://www.ecri.org/Documents/Patient_Safety_Center/hazard_MRI_080601.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/hazard_MRI_080601.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Hazard_Helical_Tacks_20040801.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Hazard_Helical_Tacks_20040801.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Hazard_Helical_Tacks_20040801.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Hazard_Helical_Tacks_20040801.pdfhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Documents/Patient_Safety_Center/BedSafetyClinicalGuidance.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/BedSafetyClinicalGuidance.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Event_Reporting_White_Paper.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Event_Reporting_White_Paper.pdfhttp://www.milbank.org/reports/Proactive/020925Proactive.htmlhttp://www.milbank.org/reports/Proactive/020925Proactive.htmlhttp://www.ecri.org/Documents/Patient_Safety_Center/RMRep1005.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/RMRep1005.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/RMRep1005.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/RMRep1005.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/RMRep1005.pdfhttp://www.milbank.org/reports/Proactive/020925Proactive.htmlhttp://www.ecri.org/Documents/Patient_Safety_Center/Event_Reporting_White_Paper.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/BedSafetyClinicalGuidance.pdfhttp://www.ecri.org/Products/Pages/Sharps_Safety_Needlestick_Prevention.aspx?sub=Worker%20and%20Environmental%20Safetyhttp://www.ecri.org/Documents/Patient_Safety_Center/Hazard_Helical_Tacks_20040801.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/Hazard_Helical_Tacks_20040801.pdfhttp://www.ecri.org/Documents/Patient_Safety_Center/hazard_MRI_080601.pdfhttp://www.ecri.org/


30/34

f e t y


31/34

A d v a n c e d

C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7


ACCE Healthcare Technology Foundation ACCE Healthcare Technology Foundation http://www.accehttp://www.acce --htf.org/htf.org/

Anesthesia Patient Safety Foundation Anesthesia Patient Safety Foundation

http://www.apsf.org/http://www.apsf.org/Premier Safety InstitutePremier Safety Institute http://www.premierinc.com/safety/http://www.premierinc.com/safety/

University of Chicago CognitiveUniversity of Chicago CognitiveTechnologies LabTechnologies Lab

http://http:// www.ctlab.orgwww.ctlab.org / /

a f e t y
http://www.acce-htf.org/http://www.acce-htf.org/http://www.acce-htf.org/http://www.acce-htf.org/http://www.acce-htf.org/http://www.acce-htf.org/http://www.apsf.org/http://www.apsf.org/http://www.premierinc.com/safety/http://www.premierinc.com/safety/http://www.ctlab.org/http://www.ctlab.org/http://www.ctlab.org/http://www.ctlab.org/http://www.ctlab.org/http://www.premierinc.com/safety/http://www.apsf.org/http://www.acce-htf.org/


32/34

A d v a n c e d

C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7

U. S. Patient SafetyU. S. Patient SafetyMovement ProgressMovement Progress

The 100,000 Lives CampaignThe 100,000 Lives Campaign3000 participating hospitals3000 participating hospitals6 interventions6 interventions

medication reconciliation to prevent adverse drug events andmedication reconciliation to prevent adverse drug events andreduction of centralreduction of central --lineline--associated bloodstream infectionsassociated bloodstream infections

The 100,000 Lives Campaign had exceeded its 18The 100,000 Lives Campaign had exceeded its 18 --month goal of preventing 100,000 deathsmonth goal of preventing 100,000 deaths Donald Berwick, CEO of the Institute for HealthcareDonald Berwick, CEO of the Institute for Healthcare

ImprovementImprovement

Premier, Inc., an alliance of nonprofit hospitals andPremier, Inc., an alliance of nonprofit hospitals andhealthcare systems, announced that its 3healthcare systems, announced that its 3 --yearyeardemonstration project with the Centers fordemonstration project with the Centers for

Medicare and Medicaid Services is resulting inMedicare and Medicaid Services is resulting inbetter care at lower costs.better care at lower costs.

a f e t y


33/34

A d v a n c e d

C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7

The Next Ten Years?The Next Ten Years?From a culture of reporting incidents to oneof learning from incidents;From an accounting approach that tabulatesevents to a synthetic approach thatsearches for patterns;From looking backward at past events tolooking forward in anticipation of future

risks;From a focus on error to a focus oncomplexity.

Authors: David Woods and Richard Cook Authors: David Woods and Richard Cook

a f e t y


34/34

A d v a n c e d

C l i n i c a l


W o r

k s h o p -

H e a

l t h c a r e


d S a

S a o

P a u

l o -

S P , B r a z i

l

N o v .

5 7

, 2 0 0 7

Questions

Comments

Discussion