esrd network 6 5 diamond patient safety program
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ESRD Network 6 5 Diamond Patient Safety Program. Patient Safety in the Dialysis Unit. Safety Culture. Culture is “the way we do things around here.” Safety culture – the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior …. - PowerPoint PPT PresentationTRANSCRIPT
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
ESRD Network 65 Diamond Patient Safety
Program
Patient Safety in the Dialysis Unit
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Safety Culture• Culture is “the way we do
things around here.”• Safety culture – the product of
individual and group values, attitudes, perceptions, competencies, and patterns of behavior ….
that determine the commitment to and proficiency of an organization’s health and safety management.
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Results of Staff Survey• Surveys items showing
high level of agreement:
• Survey items showing lowest level of agreement:
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Understanding Errors Post-Hoc• Minimize emotional component –
“…get past it and move forward.”
• Describe and understand what happened – “the facts please…”
• Gather as many perspectives as possible as to why it happened.
• Uncover “latent errors” – those contributing factors under the surface.
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Multiple Defenses Help to Prevent or Minimize Errors
Complex System Latent Failure Model
Institution
Organization
Profession TeamIndividual
Technical
DEFENSES
Accident
Near-Miss
Reports
Incomplete
procedures
Financial
constraints
Time
pressures Responsibility
shifting
No routine
Checks on
equipment
Poor Machine
Design
Broken Filter
LATENTFAILURES
ShortcutsTriggers
TheWorld
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Comprehensive Approach to Patient Safety
AnalyzeStructure in the organizationEnvironment in which care is providedEquipment/Technology used to
provide careSystems/Processes of how work is donePeople who provide the careLeadership creating the philosophy and
culture
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
StructureBasic organizational components such
as:
• Physical facilities - Designed to promote safety
• Supplies – are they appropriate and available?
• Policies and procedures – do they address safety in operations?
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
EnvironmentComplimentary to structure such as:• Lighting – e.g. inadequate leading to
falls• Temperature – e.g. too high
discouraging use of protective wear • Noise – e.g. leading to inability to hear
alarms• Ergonomics – e.g. leading to staff
injury with difficult patient transfers
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Equipment/Technology
Characteristics that promote patient safety:
• “Default” safe modes
• Pre-dialysis alarm testing
• Standardized alarm settings
• Computerized care plans
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Systems and ProcessesHow work is designed and accomplished:• Is the process too complex – too many
steps?• Is there too much variation and risk for
error?• Are procedures “evidence-based”?• Is the information needed for the next
step available?• Are procedures realistic in terms of
resources and time available?
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
PeopleImpact of human resources:
• Attitude and motivation – affects performance and attention
• Physical and mental health – affects memory, mental processing, and energy levels.
• Training and education – determines ability to respond to unexpected problem
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Leadership Systems/CultureCommitment to values underlying
safety culture:• Effective two-way communication• Blame avoidance• Human resource policies to support
safe practice• Interdisciplinary teamwork toward
common goal• Avoiding hierarchical attitudes
impeding effective communication
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Teamwork Disconnect• RN: Good teamwork means I am
asked for my input
• MD: Good teamwork means the nurse does what I say
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ESRD Network 6 (Southeastern Kidney Council) www.esrdnetwork6.org
Zeroing in on cause brings us one error closer to zero error.