Education

meaningful insights are lurking beneath the water

Dive-in to discover the power of organizational learning

Current State of Patient Safety

Patient harm is the fourteenth leading cause of the global disease burden. Healthcare is a complex system with an environment rich with potential for errors as human factors are central to the delivery of care. Error is normal, and performance is variable due to a lack of system evaluation in current review methods such as peer review and M&M conferences.

Personal blame is placed on providers for mistakes made but this is rarely true nor a complete story of the patient journey. We believe the majority of these medical errors are due to faults in the systems and processes of healthcare delivery. They are the omission of care that prevent care providers from doing their best job and allow for harm to be caused to patients.

1 in 16 Million

You have a 1 in 16 million chance of being killed by a nuclear power plant explosion.

1 in a Million

You have a 1 in a million chance of being harmed while travelling by plane.

1 in 10

The chances of you being harmed while receiving healthcare is 1 in 10 in HICs.

Annual Costs of Patient Harm

Source: OECD & WHO

 

42.7 Million

Adverse events occur globally per 421 million hospitalisations.

AUD $1.2 Billion

Spent in Australia in association with medication errors.

50%

Patient harm is associated with a medication error in Australia.

21%

Hospital stays were extended due to an adverse event in Australia.

14%

Patient harm is associated with a diagnostic error in Australia.

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Impetus

Feeling Stranded? Dive-in to Discover more Answers

Think of an iceberg. At the top, we have quality departments exhausting time and resources on identifying the causes of rare HACs and HAIs. Many have done significant work in reducing these events but, we are missing a much larger portion of findings beneath the water. These findings submerged underwater are harder to see as they are the omissions of care - the things we don't do to cause harm.

below the water

HBHS and our Collaborators have taken the fearful dive below the water to discover why patient harm is the fourteenth leading cause of the global disease burden. We have found that it is the omissions of care (e.g. misdiagnosis or failure to communicate with a patient) that contribute to the majority of patient harm. It is not the provider but the faulty processes and systems of healthcare delivery that allow care teams to cause harm.

Why have these errors been overlooked for so long?

With traditional quality monitoring, errors of omission are often invisible and hard to recognize. More importantly, a necessary culture shift needs to be achieved in which hospitals move away from shame-and-blame to taking accountability for omissions in care - to no longer view them as inherent characteristics of care. Errors of omission allow providers to cause unnecessary harm. Under no circumstances is harm justifiable. It is our duty as care providers to reduce any pain and suffering caused to our patients but it is impossible when the system continually works against us.

Traditional Review Systems

More than 80% of the time, resources and energy is spent on counting, trending, and reporting on traditionally defined adverse events (HACs and HAIs) and other regulatory requirements.

The Safety
Learning System™

Collaborative members have found that more than 80% of the failures they identify are omissions in care. Less than 20% of the harm caused can be attributed to HACs & HAIs.

Our Solution

Our Solution? A Safety Learning System™

Our Safety Learning System™ (SLS) is a systems-improvement methodology that brings together advanced workflow & analytics technology to promote organizational learning & actionable insights that will significantly reduce the harm & suffering caused by faults in the systems & processes of healthcare delivery.

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our difference

Start Learning
Together, not Apart.

Peer Review often creates an adversarial culture that builds walls in communication and causes significant emotional damage to the providers deemed responsible. We aim to foster a culture of accountability, respect, openness, and support through multi-disciplinary and -speciality case discussion meetings founded on a respect for deference to expertise. This is followed by a process of knowledge dissemination intended to share learnings as broadly as possible.

Method of Diagnosis

The Safety Learning System™ reviews patient journeys through a standardized case review method to "diagnose" process & system failures that allow providers to cause unintentional harm. The Safety Learning System™ review process integrates:

Clinical Expertise

Every case is reviewed by a practising nurse and physician who can best assess the patient journey, care team dynamics, & organizational barriers.

Continuous Education

The Safety Learning System™ process of case review is designed to encourage continual learning by enabling organizational & personal awareness among participants.

Resilience Engineering

The Safety Learning System™ is built to encourage resilience in providers by designing reliable systems & hospital cultures that support caregivers.

Quality Improvement

Identifying omissions in care allows for the implementation of targeted QI projects that make a lasting difference without exhausting resources.

Clinical Informatics

Our Healthcare Safeware® technology acts as a central registry for your organization that enables the meaningful collection & reporting of insights.

Organizational Learning

Hospital leadership is inspired & informed by practising staff who know the work best & know what needs to be fixed to help both patients & providers.

Systems Engineering

The processes & systems of healthcare delivery, not the individual, are examined to pinpoint the common causes of patient harm previously unidentified.

Implementation Science

The Safety Learning System™ integrates innovative Change Management methodologies that adhere to your organization's culture & resources.

"In the past, medical errors were thought to be the result of individuals behaving badly. We blamed the doctor who ordered the wrong treatment, the pharmacist who dispensed the wrong dose, or the nurse who gave the medication to the wrong patient. This idea that adverse events were due to bad people led to a “deny and defend” culture among healthcare professionals and prevented progress on patient safety. Today, we know better. We know that medical errors are largely the result of bad systems of care delivery, not individual providers."

~Ashish Jha

Reconciling Healthcare with High Reliability

The Safety Learning System™ is rooted in high-reliability engineering. The Safety Learning System™ intends to create reliable systems of care ensuring the four rights of healthcare: right person, right place, right time, right provider.

Sensitivity to Operations

Our Safety Learning System™ increases situational awareness among participants to notice organizational barriers that allow for harm to be caused every day.

Deference to Expertise

Deference to expertise is most simply a respect for professional knowledge regardless of hierarchy. We honour this principle throughout the entire process.

Commitment to Resilience

Care providers are directly involved in this work allowing them the opportunity to change the system so it works for them in the hopes of reducing provider burnout.

Resistance to Simplification

All of our guiding principles encourage participants to resist the oversimplification of issues so that targeted QI projects can be locally developed & implemented.

Preoccupation with Failure

Patient harm is an everyday occurrence but it is often treated as an anomaly. Our methodology encourages participants to anticipate failures before they happen.

Perpetual Reinvention

HROs continually reinvent themselves. We at HBHS believe that the age-old excuse of 'things have always been done this way' is not only obsolete but dangerous and catastrophic.

Guiding Principles of the Safety Learning System™

System Review

This work is about identifying the system & process faults in healthcare delivery that prevent care providers from doing their best job & allow for mistakes to be made. Reviewers must adopt a system perspective allowing them to understand the patient journey as a whole rather than scrutinizing individual actions.

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Deference to Expertise

Deference to expertise means turning to those who know the work best, respecting their knowledge, and considering their input when reaching a decision or formulating a plan. This principle is directly carried into the review process by having a practising nurse and physician review each case.

MultiLens Discussion

MultiLens case discussions are held regularly during which audience members from various specialities & disciplines discuss reviewed cases. During these meetings, reviewers present their cases followed by audience members discussing the issues identified by reviewers. Audience members must reach 100% agreement on whether or not the issues identified exist. The consensus then creates Opportunities for Improvement (OFIs).

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Local Implementation

Local implementation allows for hospitals to right-size quality improvement projects by gathering & interpreting their own data; discovering what needs to be fixed according to their own hospital systems & processes, and; determine how to create & institute changes based on their own resources.

Central Registry

Case review findings should be recorded centrally to help aggregate & reconcile the data across your hospital or healthcare system. Our Healthcare Safeware® technology aids in the discovery of actionable insights through a combination of data gathering, analytics, interpretation & visualization.

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Outcomes of a Safety Learning System™

Enforced Reliability

System review leads to insights that allow for systems to be redesigned in a way that enforces reliable care: right person, right place, right time, right provider.

Right-Size QI Initiatives

Local implementation gives hospitals the power to determine what changes will be made & how they will be instituted depending on their individual needs, local culture & available resources.

Situational Awareness

Practising providers that participate in case review will ultimately improve their situational awareness. They are given the opportunity to learn about how everyone in the hospital performs.

Culture Change

Providers will become more collaborative in their effort to care for a patient because of our respect for the principles of deference to expertise & MultiLens discussion.

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Testimonials

Diving Deeper to
Discover & Learn More

With traditional review methods, many opportunities are missed because the focus of review is too narrow & learnings are isolated to the individual. The Safety Learning System™ is a significant shift from traditional review as it broadens the focus of case review, narrows findings through consensus during MultiLens discussions, shares learnings as broadly as possible, and targets potential improvements through local implementation & a central registry.

Inspirational Moment

The Zavodovski Island is an environment of extremes, just as healthcare, making life exceptionally difficult for its inhabitants – the Chinstrap Penguin. The Chinstrap faces jagged rocks and forceful waves to get food. He must risk death to survive or die not trying. Similarly, we must improve healthcare by taking risks because the only way to survive is to dive!

Interested? Keep exploring, follow us on social media, or contact us on how to get started!

HB Healthcare Safety® is a Social Benefit Corporation offering systems-improvement & technology resources to reduce the harm caused by care delivery. We believe that no one should ever suffer or die as as the result of system or process failures in care delivery.

Copyright of HB Healthcare Safety®, SBC 2019.

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