Isn’t it time to end the loss of life from preventable medical errors? Each year 100,000 patients die from preventable errors in the U.S. How can you help to change this intractable problem? Knowledge is power, and this course will provide you with a deep understanding of the problems and the solutions. You can become part of the solution.
Plan-Do-Study-Act
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来自 University of Florida 的课程
如何改进医疗保健服务
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从本节课中
Understanding and Preventing Human Error Part I
This module will be discussing the consequences of medical errors, and you will learn from Sorrel King's loss of her daughter, Josie, and from my personal experience that preventable injuries not only cause death but also can lead to permanent life changing injuries. Sitting around and doing nothing is not an option. However we all need to understand and use three key tools to determine the causes of medical errors and to fix them, Root cause analysis, Driver Diagrams, and PDSA cycles. Finally we will discuss the issue of small errors and our tendency to ignore and workaround them. Unfortunately this approach to small problems is one of leading causes for the continued high rate of preventable injuries and deaths in our hospitals and clinics. It is time to fix the little things.
与讲师见面
Frederick S. Southwick, MDProfessor
College of Medicine
Believe it or not everyday you go through a PDSA cycle.
For example, everyday when you get in your car and start to go to work.
You go through a PDSA cycle.
You get in the car, you listen to the radio,
you've planned your trip, you're heading down the road, and
then you're told that in fact there is a wreck on a road that you typically use.
So you've planned your journey, you're doing it,
you're studying it now because you're getting feedback off the radio and
then you discover that this road is closed.
So what do you do?
You take that information you put it into your brain and then you say, I'm gonna
get off this road and I'm gonna take a different route to avoid that accident.
You've just gone through a PDSA cycle.
Similarly, let's say that you had a sick house plant, and
this plant was not doing too well.
You could try a number of things.
You could try more water.
You could try fertilizer.
You could try a bigger pot because it's root bound.
You could try a variety of things, but again you would be doing plan, do,
study, act.
So as we think about the PDSA cycle, it is a very simple thing,
yet many people can describe it but they've had trouble carrying them out.
Historically, the PDSA cycle was developed by a gentleman by the name of
Walter Shewhart.
Walter Shewhart, back in the 1920s, working at Western Electric, in Cicero,
Illinois, and in New Jersey, took the scientific method that is inductive and
deductive thinking where you go from the specific to the general,
from the general to the specific with hypothesis testing.
He took that scientific method and turned it into a very simple notion that when
we're going to do something, we're gonna plan it, do it, study, and act.
Now remember Shewhart and his students Deming and Jeran, were working on
the shop floor at Western Electric, they could not as PhD's trained in physics,
engineering, statistics, take the academic scientific method and
apply it to shop floor, where people were working making old fashioned telephones.
Those people, many of which did not read, could not explain the scientific method,
were very, very engaged because Shewhart was able to take the complexity
of this and turn it into a very simple thing that we do everyday.
Plan, do, study, act.
This then becomes a way we carry out a test.
Every day you're doing something whether you think about it or not,
you're actually doing a PDSA.
What we're trying to do is when we give you a PDSA form, and
you're gonna fill out this PDSA form.
You're actually going to say here's my plan.
Bullet, bullet, bullet.
Here's how we're gonna do it, and here are the people.
Mary's gonna do this,
Bill's gonna do that, Tom's gonna do this, we're gonna study it.
We're gonna get some data, and we're gonna collect it,
we're gonna track it, see how the process performed against that test, and
then we're going to act by modifying it and come back up and plan our next cycle.
PDSA is not a one time event where you do it once and then go away.
What you do is actually do these.
You link them sequentially and they move forward.
Test one, test two, test three.
And so we're going to link the PDSAs starting out in small test.
You're gonna start with one patient, on one day, possibly.
Then you might move to three patients.
Then you might move to five patients, and eventually you can apply it to all.
But it requires testing under a variety of conditions.
So we start small, with small test of change.
And then we start testing them under different conditions.
It worked well in this unit, but then when you went over to the next unit and
tested that same notion it didn't work too well.
Why?
Different conditions, different people, different variation in the process.
So everyday you're gonna have the opportunity to think about applying
these things in a very, very practical yet concerted way.
>> As Bob Lloyd states, every day we go through a PDSA cycle.
This tool can improve your life.
It can be used to lose weight, improve your exercise program,
get more sleep at night.
As we have learned a very important requirement for
your brain to function at a high level.
To become more punctual and
to even improve your conversation with friends and family.
As Bob discussed in his first white board class PDS cycles need to
be repeated multiple times before the most efficient and
effective process for solving the problem can be achieved.
When beginning a PDSA cycle, it's important to ask three questions.
What am I trying to accomplish?
What changes can I make that will result in an improvement?
How will I know that the change is an improvement?
Let me share a personal improvement project that I
undertook several years ago.
What am I trying to accomplish in this project?
Consistently carry on meaningful conversations with my wife,
Kathie that enable us to share each other's daily lives and
create in her a sense of being valued and heard.
What factors are interfering with me achieving this goal?
Let's look at the driver diagram.
I placed asterisks next to the most important primary drivers.
Paying attention and identifying topics of mutual interest.
The secondary drivers for these two primary drivers,
my attention is reduced when I am distracted by my computer,
or if I don't completely stop working
my mind tries to return to my work task resulting in a superficial conversation.
Also if I become at all sleep deprived, my concentration deteriorates.
Also I am a morning person and I become sleepy between 2 and
4 PM, particularly, if I haven't had 8 hours of sleep.
The second important driver is identifying topics of mutual interest.
Kathie and I work in very different fields, and
therefore need to build shared expertise.
Kathie runs a school for troubled teenage girls, and
I am an infectious disease specialist and expert in patient quality and safety.
We rarely read the same books, and quite frankly,
I had rarely considered the topics that were of interest to Kathie.
During our conversations, I had a tendency to go off on long monologues,
rather than asking guiding questions or asking Kathie's opinion.
The right column shows the potential solutions.
I have placed double asterisks next to the ones that were most likely to be affected
and single asterisks on the other potential improvements.
Now, let's look at my first PDSA cycle based on this analysis.
I chose two interventions, my plan was to stop all work and
shut down my computer at the first ring of the phone.
And secondly, rather than going on and
on, I asked Kathie questions about her day and listened.
In the second cycle, I generated a list of topics that would be of mutual interest.
Our children, her work as the head of the girl's school,
our parents' emotional and physical health, our relationship, our friends,
national world news, books, and her book club.
For my third cycle, I made sure I got eight hours of sleep each night.
So how did I determine if my changes were improvements?
We decided on a five point grading scale.
One, not valued or heard, up to five,
felt strongly valued and heard.
So what happened the first time Kathie called?
It was 11 AM and I shut off my computer and I stopped all work.
I asked questions and listened.
Kathie was pleased but
feared these dramatic improvements could not be sustained.
She gave me a grade of 4.
Her second call was later that day at 9:45 PM.
I was working on a journal review when Kathie called.
I trouble switching from the scientific journal review to more social
interactions I was not as effective at asking questions or paying full attention.
Kathie was really disappointed, and I received a grade of three.
I decided at this point to create my list of common interest topics.
The second PDS six cycle.
Wow.
What a change.
Our conversation became far richer.
We shared mutual interest and covered 5 different topics and the conversation
lasted nearly 30 minutes, our longest conversation in the past 2 weeks.
I received a score of five.
My changes represented a dramatic personal improvement and
I consistently scored five from that time on.
Now let's apply PDSA cycles to the fatal medication mix up
I described in our previous session.
What am I trying to accomplish?
Prevent future switching of IV norepinephrine for cefepime.
Let's look again at the driver diagram.
I placed double asterisks next to the improvement
plans that I think will have the biggest impact.
Changing the color and labeling of the bag
as well as changing the coloring of the IV tubing.
For the first PDSA cycle,
I chose to label the norepinephrine red and also color the tubing red.
To measure the effects of these changes,
we chose a simulation exercise involving ten nurses doing ten tries
first connecting the lookalike medical bags following a pager interruption.
These are the predictor results, and we have not actually performed the trial.
As shown in this slide, the percentage of mix-ups range
from 10 to 50% using the look-alike medication bags and clear tubing.
Following the change in medication bag and
IV tube in color, an increase in the size of the label
one nurse mixed up the medications after being distracted by the pager.
Subsequent nurses never mixed up the medications.
Everyone in healthcare needs to become an expert at PDSA cycles.
Patients can apply them to improve their health, and caregivers can apply them
to improve the efficiency, quality, and safety of patient care.
Now Bob Loyd will describe how PDSA cycles
can be used to improve another key clinical process.
Discharge planning.
>> So let's apply the PDSA cycle to an actual example.
Let's take, for example, discharge planning.
That is, getting a patient out of the hospital,
on time when they were told they'd be discharged, which pleases the patient,
the family, and the next set of patients that need to come in.
So what is our plan?
The first plan aspect that we're going to do is that we've worked with a team to
develop a new discharge planning form.
Now, this form is a task.
That has to be done in order to achieve a test.
And oftentimes, people get confused between a task and a test.
The test is going to be taking the form and applying it to a patient.
So now, this form has check boxes.
It has pharmacy,
it has discharge planning instructions, education, other things that are needed.
Now we're gonna do it.
That is, on next Monday, we're going to get one of the discharge planning nurses,
Tom, to take this form and apply it to three patients.
We're not gonna do it on all 50 patients.
We're not gonna do it on the whole hospital.
We're gonna start out with a small test, three patients.
Tom's gonna take the form and use it with these three patients.
We're gonna get feedback then.
We're gonna study, and Tom is gonna come back.
And we're gonna get feedback from Tom on whether or not the form worked.
Were things easy to fill out?
Did he have to look all over the place?
Did the flow of information work well?
So Tom's gonna give us feedback.
Then we're also gonna get feedback by keeping track of the percent of
patients discharged by 11 o'clock.
And we're gonna keep this little run chart to look at our progress over time and
as we do more tests, we're gonna accumulate more data and eventually,
we'll be able to see if in fact this form and what goes with it is actually
improving the percent of patients that get discharged less than 11 AM.
Then we're going to act.
We're gonna take the feedback from Tom and from our data, and then we're going to
think about the next test with more patients maybe on a different unit.
Maybe now, we're gonna take it instead of just from 3 west.
We're gonna take it and apply it to all med search floors.
Now, when we've tested under different conditions, and we're now accumulating,
we've tested it with 3, 5, 10,
15 patients, at some point after we've tested, under different conditions,
we're gonna be ready to move to the next phase, which is to implement.
That is, implementation of the test, in this case, the form, to all units.
But we wouldn't wanna do that until we've tested especially under different
conditions.
And finally,
once we've implemented, we'll be ready to engage ourselves in some spread.
Let's say that we are part of a system, and that system has three hospitals.
So we've been testing it starting on one unit,Tom's unit.
Then we're gonna go to this hospital.
Then we're gonna move to the next two hospitals and
spread that, that has been tested and documented.
But it all starts with our PDSA cycle and allows us to give a framework for
testing one idea against a group of patients that eventually will be
allowed to implement and to spread on a regular basis.
It all starts with the testing of PDSA.
