Understand the Science of Safety for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Understand the Science of Safety for Perinatal Safety
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
- Describe the historical and contemporary context of the Science of Safety.
- Explain how system design affects system results.
- List the principles of safe design and identify how they apply to technical work and teamwork.
- Indicate how teams make wise decisions when there is diverse and independent input.
Slide 3: Health Care Defects
In the U.S. health care system—
- 7 percent of patients suffer a medication error.1
- In 1999, it was estimated that 44,000 to 99,000 people die in hospitals each year as the result of medical errors.2
- More recent estimates suggest that between 210,000 and 440,000 patients who go to a hospital each year suffer some type of preventable harm that contributes to their death.3
- Over half a million patients develop catheter-associated urinary tract infections resulting in 13,000 deaths a year.4
- Nearly 100,000 patients die from health care-associated infections (HAIs) each year, and the cost of HAIs is $28 billion to $33 billion per year.5
Slide 4: How Can These Errors Happen?
- Health care professionals are humans, and humans are fallible.
- Medicine is still treated as an art, not a science.
- Systems do not catch mistakes before they reach the patient.
Image: A sign indicating a wet floor is removed while the floor is still wet. As a result, a patient slips on the floor.
Slide 5: The Science of Safety
- Every system is perfectly designed to achieve its end results.
- Safe design principles must be applied to technical work and teamwork.
- Teams make wise decisions when there is diverse and independent input.
Slide 6: System-Level Factors Affect Safety6
Image: Concentric circles show the layered impact of patient safety. Institutional factors, hospital factors, departmental factors, work environment factors, team factors, individual provider factors and task factors all have an impact on patient safety.
Slide 7: System-Level Factors Can Predict Performance
| Examples of Impact of System-Level Factors | |
|---|---|
| System Factor | Effect |
| Nurse-to-patient ratios regularly exceed best practice | When nurse-to-patient ratios regularly exceed best practice based on the unit's acuity and rate of volume change, there is an increased risk of patient complications. |
| Hierarchy issues | Disrupted the ability of unit nurses and doctors to work effectively together with respect to labor induction policies. A shift in authority led to a significant drop in the number of reported birth complications. |
Slide 8: Three Principles of Safe Design
Image: Three principles of safe design include: standardize, create independent checks, learn from defects.
Slide 9: Standardize When You Can
Image: Opening shot of "Standardize When You Can" video with the words "Click to play" on the front.
Go to Link Below To Play Video:
https://www.ahrq.gov/hai/cusp/videos/04c-standardize/index.html
Slide 10: Create Independent Checks
Image: Opening shot of "Standardize When You Can" video with the words "Click to play" on the front.
Go to Link Below To Play Video:
https://www.ahrq.gov/hai/cusp/videos/04d-independent-checks/index.html
Slide 11: Learn From Defects
Image: Opening shot of "Standardize When You Can" video with the words "Click to play" on the front.
Go to Link Below To Play Video:
https://www.ahrq.gov/hai/cusp/videos/04e-learn-defects/index.html
Slide 12: Principles of Safe Design Apply to Technical Work and Teamwork
Image: Opening shot of "Principles of Safe Design Apply to Technical and Teamwork" video.
Go to Link Below To Play Video:
https://www.ahrq.gov/hai/cusp/videos/04f-tech-teamwork/index.html
Slide 13: Teams Make Better Decisions When There Is Diverse and Independent Input
Image: Opening shot of "Principles of Safe Design Apply to Technical and Teamwork" video.
Go to Link Below To Play Video:
https://www.ahrq.gov/hai/cusp/videos/04g-diverse-input/index.html
Slide 14: How To Ensure Diverse and Independent Input
- Appreciate the wisdom of crowds:
- Emphasize that health care is a team effort.
- Develop an environment of mutual respect in which frontline providers can voice concerns, and are acknowledged when they express concerns.
- Gather as many viewpoints as possible.
- Alternate between convergent and divergent thinking7
- Divergent thinking occurs during brainstorming sessions and when trying to understand what might be occurring.
- Convergent thinking occurs while formulating a treatment plan or focusing on a specific task.
Slide 15: Basic Components and Process of Communication8
Image: Graphic description of the basic components and process of communication. The communication that takes place between two people is exposed to many roadblocks in between its transmission from one individual to another. First, the message is encoded, or created, by the sender who then transmits the message to the receiver, who then must decode, or process, the message. While the message is being transmitted, it is exposed to noise interference that impacts the context and clarity of the message that is sent and received.
Slide 16: Understand the Science of Safety: What the Team Must Do
- Develop a plan so all staff on your unit view the Understand the Science of Safety videos
- Track staff participation in viewing the videos
- Staff should be able to describe the three principles of safe design:
- Standardize
- Create independent checks
- Learn from defects
Slide 17: Summary
- Every system is designed to achieve its end results.
- The principles of safe design are: standardize when you can, create independent checks, and learn from defects.
- The principles of safe design apply to technical work and teamwork.
- Teams make better decisions when there is diverse input.
Slide 18: References
- Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274(1):29–34. PMID: 7791255.
- Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
- James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. J Patient Saf 2013;9:122-128. PMID: 23860193.
- Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. https://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. Accessed October 8, 2014.
Slide 19: References
- Klevens M, Edwards J, Richards C, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals 2002. PHR 2007;122:160–166. PMID: 17357358.
- Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154–57. PMID: 9552960.
- Heifetz R. Leadership Without Easy Answers. Cambridge, MA: Harvard University Press; 1994.
- Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf 2007;33(1):34–47. PMID: 17283940.
Slide 20: Disclaimers
Every effort was made to ensure the accuracy and completeness of this resource. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
The U.S. Department of Health and Human Services cannot endorse, or appear to endorse derivate or excerpted materials, and it cannot be held liable for the content or use of adapted resources. Any adaptations of this resource must include a disclaimer to this effect.
Reference to any specific commercial products, process, service, manufacturer, company, or trademark does not constitute endorsement or recommendation by the U.S. Government, HHS, or AHRQ of the linked Web resources or the information, products, or services contained therein. The Agency does not exercise any control over the content on these sites.
