Safety Score Audit

Logical Development

1.Institute of Medicine 1999 Report “To Err is Human”…
a.Found that there were up to 100,000 preventable deaths in American hospitals every year.
b.On consideration they acknowledged that doctors and nurses don’t go to work to harm people
c.Closer examination revealed that the cost of most bad outcomes was due to “systems failures”
d.Example: Young man in hospital with Leukaemia and brain metastases. Has a cannula in vein in his arm (for pain relief and chemotherapy) and cannula in his spinal canal (for pain relief). On a weekend an intern mistakenly injects chemotherapy into the spinal canal. Patient has a prolonged seizure and dies. On review of this case it became apparent a number of systems failed at the same time – Charge Nurse of the oncology ward was relieving in another job. The Intern was only qualified as a doctor for a few weeks. The ward pharmacist was sick and it was a weekend. If any of one of these exceptions had not existed, the error would have been detected and prevented
e.British psychologist, James Reason explained this with his Swiss Cheese model. This shows that usually 4 or 5 systems must “fail” at the same time for a patient to suffer a bad outcome

2.“No Blame Culture” or “Just Culture”
a.Was developed to reduce these preventable patient deaths and other morbidity
b.In simple terms, if I as a clinician make a mistake, even if there is not a bad outcome, I should inform my boss and together we would develop a safety mechanism to prevent me, or another clinician, from making the same mistake in the future.
c.The “No Blame” or “Just Culture” means that if it was an honest mistake I will not get into trouble. I probably already feel terrible that the mistake has occurred.
d.In the old days, I probably would have kept quiet to avoid being disciplined or ridiculed and the error would have been repeated over and over again
3.Sharps injuries to ER resident
a.When 2 of our senior residents recently sustained sharps injuries the language they used when reporting the accidents was quite revealing
b.One said “It was my fault I wasn’t concentrating”; the other “It was my fault I was rushed”
c.This “Self Blame” or “Blame Worthy” culture is in direct contradiction to the “No Blame” culture aimed at improving patient safety.
d.It means that the clinicians will avoid further sharps injuries by never being rushed again – an impossibility in a chaotic Emergency Room or any busy job
e.As a consequence they will never look externally for a solution to protect them and their colleagues from a similar fate
4.This “schizophrenic” mind set
a.Means that clinical staff are supposed to operate in a “No Blame” culture for patient safety, but a “Self Blame” culture for staff safety. An incongruous, if not impossible position
b.This observation led to my hypothesis (published in the BMJ), that “ a culture of staff safety is a pre-requisite to a good culture of patient safety”
c.What we need is one “Just Safety Culture” for everyone – Staff and Patients alike.
5.Evidenced Based Medicine
a.Found that if a doctor or nurse attends a 3 day conference they will probably only learn 2 or 3 new facts – even it they are conscientious and attend all the lectures
b.The chance of them changing their clinical practices is close to zero
c.On the other hand, Evidence Based Medicine has found that “clinical audits” are the best means of changing clinicians practice.
6.The idea of “Safety Score Audits"
a.Was the logical conclusion to the above observations as summarised by a cartoon in my 2013 AORN Poster

Text reads:

1. Audit works

2. Audit works

3. Audit works

4. See Rule 1

Safety Score Audit Overview:

1.Examples to trial first………..
a.Syringe Safety Score = Number of Safety Syringes / total number of syringes purchased in a year
b.Scalpel Safety Score= Number of safety scalpels + Number of single handed blade removers / total number of scalpel blades purchased in a year
c.Suture Needle Safety Score = Number of blunt suture needles / total number of suture needles purchased in a year
2.Suggested Use
a.Joint Commission will assess the “Scores”  that are produced by the Hospital as part of their accreditation visit
b.A poor score would be the basis for an intervention, for example
i.Education by OSHA staff  in relation to bloodborne pathogens guidelines
ii.Failure to improve may lead to a fine
c.Parallel Research opportunities to dig deeper than this broad-stroke audit tool
3.Expected Outcomes……
a.Improved Staff Safety
b.Flow on effect to improve Patient Safety
4.Safety Scores are ………
a.An implementation tool based on established Occupational Health & Safety principles
b.They are not new legislation or guidelines in their own right

Safety Score Audit Examples

Table 1: Syringe Safety Score (SySS)

Type purchased

Safety type

Formula

Case 1

Case 2

Case 3

 

 

 

 

 

 

Standard

Unsafe

A

500

300

300

Guard

Active

B

350

400

300

Spring loaded

Passive

C

350

500

600

 

 

 

 

 

 

Total syringes

 

A+B+C

1200

1200

1200

 

 

 

 

 

 

Overall Safety Score

 

B+C/A+B+C

700/1200

= 0.58

900/1200

= 0.75

900/1200

0=.75

 

 

 

 

 

 

Active Safety Score

 

B/A+B+C

350/1200

= 0.29

400/1200

= 0.33

300/1200

= 0.25

 

 

 

 

 

 

Passive Safety Score

 

C/A+B+C

350/1200

= 0.29

500/1200

= 0.42

600/1200

= 0.50

Table 1 shows that the overall safety score improves when more safety devices are purchased (Case 1 vs Case 2). Furthermore it highlights the importance of looking at passive (automatic) safety vs active (manual) safety devices (Case 2 vs Case 3) where the overall safety score is the same but in Case 3 the passive score is higher. It is the authors’ prediction that this audit process will show better staff safety outcomes when passive safety devices are used more frequently than active safety devices.

 

Table 2: Scalpel Safety Score (ScSS)

Type purchased

Safety type

Formula

Case 1

Case 2

Case 3

 

 

 

 

 

 

Standard Scalpel Blades

Unsafe

A

500

400

500

Safety Scalpel

Active

B

100

200

100

Single Handed Scalpel Blade Remover*

Passive

C

100

100

200

 

 

 

 

 

 

Total Scalpel Blades

 

A+B

600

600

600

 

 

 

 

 

 

Overall Safety Score

 

(B+C)/(A+B)

200/600 = 0.33

300/600 = 0.50

300/600 = 0.50

 

 

 

 

 

 

Active Safety Score

 

B/(A+B)

100/600 = 0.17

200/600 = 0.33

100/600 = 0.17

 

 

 

 

 

 

Passive Safety Score

 

C/(A+B)

100/600 = 0.17

100/600 = 0.17

200/600 = 0.33

Table 2 shows a similar situation where an example of the Scalpel Safety Score Audit is displayed. In this case the preferred method of scalpel safety is the one using the passive single handed remover.

 

Table 3: Suture Needle Safety Score (SnSS)

Type purchased

Safety type

Formula

Case 1

Case 2

 

 

 

 

 

Standard Needles

Unsafe

A

900

800

Blunt Tipped Needles

Active

B

100

200


 

 

 

 

 

 

 

 

 

Total Suture Needles

 

A+B

1000

1000

 

 

 

 

 

Overall Safety Score

 

B/A+B

100/1000
=0.10

200/1000
=0.20

Table 3 shows the case for Suture Needle Safety Score Audit. At this stage the only safe alternative is blunt tipped suture needles that can be successfully used to close muscle and fascia

 

State of Michigan House Resolution No. 11

 

 

Organisation
Physical Safety
Ethical Safety
Global Change