Understand the Science of Safety Module Alternate Text
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Slide 1 Cover Slide |
(CUSP Toolkit logo) | The "Understand the Science of Safety" module of the CUSP Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected and are aimed at improving patient safety. | |||||||||||||||||||||||||||
Slide 2 Learning Objectives |
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Slide 3 Putting Safety in Context |
Advances in medicine have led to positive outcomes:
However, sponges are still found inside patients’ bodies after operations. |
Team members examining a patient’s X-ray. | |||||||||||||||||||||||||||
Slide 4 Health Care Defects |
In the U.S. health care system:
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Slide 5 How Can These Errors Happen? |
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A sign indicating a wet floor is removed while the floor is still wet. As a result, a patient slips on the floor. | |||||||||||||||||||||||||||
Slide 6 The Science of Safety |
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A group of team members conferring. | |||||||||||||||||||||||||||
Slide 7 System-Level Factors Affect Safety9 |
Concentric circles show the layered system-level factors that affect patient safety: institutional factors, hospital factors, departmental factors, work environment factors, team factors, individual provider factors, and task factors all have an effect on patient safety. | Concentric circles show the layered system-level factors that affect patient safety: institutional factors, hospital factors, departmental factors, work environment factors, team factors, individual provider factors, and task factors all have an effect on patient safety. | |||||||||||||||||||||||||||
Slide 8 Safety is a Property of the System |
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Slide 9 System-Level Factors Can Predict Performance |
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Outcomes gained from small system factors can result in a monumental impact on safety performance. Having an intensivist on daily ICU rounds with a multidisciplinary team can reduce patient mortality. Having a nurse responsible for more than two patients in the ICU can increase the patient populations’ risk of pulmonary complications. Having a point-of-care pharmacist or a pharmacist who participates in rounds can help reduce prescribing errors. | |||||||||||||||||||||||||||
Slide 10 Three Principles of Safe Design |
Three principles of safe design are standardize, create independent checks, and learn from defects. | Three principles of safe design are standardize, create independent checks, and learn from defects. | |||||||||||||||||||||||||||
Slide 11 Standardize When You Can |
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Slide 12 Create Independent Checks |
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Slide 13 Learn From Defects |
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Slide 14 Exercise |
Think about a recent safety issue in your unit and answer the four Learning from Defects questions:
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Slide 15 Principles of Safe Design Apply to Technical Work and Teamwork |
Team members next to a line cart. | ||||||||||||||||||||||||||||
Slide 16 Technical Work and Teamwork |
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Video icon Principles of Safe Design Apply to Technical and Teamwork [will insert alt text to PowerPoint once video is inserted] |
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Slide 17 Exercise |
How do you see technical and adaptive work fitting in your unit? | Exercise icon | |||||||||||||||||||||||||||
Slide 18 Teams Make Wise Decisions When There is Diverse and Independent Input |
A health care team | ||||||||||||||||||||||||||||
Slide 19 How To Ensure Diverse and Independent Input |
Appreciate the wisdom of crowds
Alternate between convergent and divergent thinking
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Slide 20 Basic Components and Process of Communication11 |
Provider A – Sender and Receiver
Messages
Provider B – Sender and Receiver
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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 sender encodes, or creates, the message, which is influenced by the sender’s context, and then transmits the message to the receiver, who then must decode, or process, the message, based on the receiver’s context. While the message is being transmitted, it is exposed to noise interference that affects the context and clarity of the message that is sent and received. | |||||||||||||||||||||||||||
Slide 21 Diverse and Independent Input |
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Slide 22 Reduced CRBSI By Applying Principles of Safe Design12 |
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Over various time periods, the Median Catheter Related Blood Stream Infection (CRBSI) rate reduces in conjunction with the Incidence Rate Ratio: Baseline infection rate of 2.7 with an incidence rate ratio of 1 Pre-Intervention infection rate of 1.6 with an incidence rate ratio of 0.76 0-3 months: infection rate of 0 with an incidence rate ratio of 0.62 4-6 months: infection rate of 0 with an incidence rate ratio of 0.56 7-9 months: infection rate of 0 with an incidence rate of 0.47 10-12 months: infection rate of 0 with an incidence rate of 0.42 13-15 months: infection rate of 0 with an incidence rate of 0.37 16-18 months: infection rate of 0 with an incidence rate of 0.34 |
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Slide 23 Understand the Science of Safety: What the Team Must Do |
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A team conferring at a table. | |||||||||||||||||||||||||||
Slide 24 Summary |
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Slide 25 CUSP Tools |
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Slide 26 TeamSTEPPS Tools1 |
*Please refer to the "Implement Teamwork and Communication" module for additional information* |
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Slide 27 References |
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Slide 28 References |
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Slide 29 References |
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