All too many of our patient safety activities are after-the-fact. Much of what we monitor is time-consuming, labor-intensive and costly and often reactive in nature. Because it is after-the-fact, staff often feel that it is punitive rather than constructive. We are big fans of those patient safety activities that are more proactive and can help capture vulnerabilities before they give rise to adverse patient outcomes. That is why we like activities such as FMEA (failure mode and effects analysis), ICU daily goals, and patient safety walk rounds.
A somewhat lesser known proactive patient safety activity is the real-time random safety audit (RSA). An excellent article appears in the March 2010 Clinics in Perinatology (Ursprung 2010) by authors who have pioneered this technique in neonatal intensive care unit (NICU) settings. The same authors had published the impressive outcomes of RSA in the NICU setting in 2005 (Ursprung 2005).
Other industries (eg. banking, pharmaceuticals, steel making, etc.) have used such random audit techniques successfully for many years. We’ve previously talked about the line operations safety audits (LOSA) audits in aviation where an independent observer sits in the cockpit and monitors and assesses multiple operations and procedures, then critiques the crew. But the LOSA is resource-intense, requires a well-trained auditor, and behavior may be quite different when a known audit is being undertaken. So many industries have adopted the simple real-time random safety audit. Ursprung and colleagues used trained research nurses to do the audits in their 2005 study but now use frontline staff for day-to-day RSA’s.
The concept is simple. Each day you randomly choose (from a list of patient safety items your organization has deemed to be important) some process or condition or piece of equipment for auditing. Your list should be developed by a broad interdisciplinary team to reach consensus on prioritizing areas of importance for the unit in question. You then do your audit and provide immediate feedback to frontline staff. The person performing the audit could be a nurse, pharmacist, physician, respiratory therapist, or other appropriate individual. The important concept is to involve as many different disciplines as are relevant to that unit. That is very helpful in fostering a culture of patient safety on the unit.
One of the keys is keeping the number of questions and items to a manageable level, at least at the start. Ursprung and colleagues suggest 5-15 questions to start with. They also recommend making a deck of printed cards, each containing a single question. There are multiple copies of each question in the deck. You shuffle the deck so that you get the questions in a randomized fashion. For items considered to be of higher priority, you can include more cards with that particular item so that you are more likely to address it during the random process.
Each day one card is selected and then all relevant patients (or equipment, etc.) are audited for the question on that card. For example, you might look at procedures done on patients and have several cards with questions like “If a procedure was done on this patient in the past 48 hours (remember one question per card):
A real value of the RSA is the ability to give timely feedback to frontline staff. That is why the RSA is a good method for improving compliance with things like your dangerous abbreviations list. All too often we audit our dangerous abbreviations retrospectively, then give providers several weeks later notice of the times they used those abbreviations. They often feel offended and we hear comments like “So shoot me.”. Instead, when you look at dangerous abbreviations during an RSA you can give immediate feedback and are often in a better position to point out how use of that abbreviation might be confusing to nursing or pharmacy.
Other considerations for the RSA are communication issues, in-house transport issues, timeliness of reports or consultations, delays in care, medication reconciliation, hand hygiene, use of catheters and other indwelling objects, care bundle compliance, alarms, device settings, pain management, oxygen use, and many others.
Of course, you also need to aggregate your results and report back on a regular basis at staff meetings, QI committee meetings, etc. But make sure that your use of audit findings is applied in a constructive fashion and avoid any semblance of punition or you may destroy the positive changes in safety culture.
The 2005 study (Ursprung 2005) identified numerous problems related to patient identification bands as well as problems related to delays in care, equipment issues, and others. Not only did their audit result in some immediate feedback to correct problems, but their project also resulted in a change in the patient identification process and revision of guidelines for pulse oximetry alarms. Their original study was done using a research nurse and they asked 5-7 questions per patient, which proved to be quite time-consuming. Therefore, the audit changed to the currently recommended format of one question per patient.
The 2010 article has a great appendix with numerous examples of questions that were addressed in RSA’s in the NICU setting. However, most of them are easily adaptable to other settings. You should also keep in mind that things in many healthcare settings differ by day of the week or time of day. So consider doing your RSA on evenings and weekends as well. That also helps foster involvement of all frontline staff in the patient safety process.
The authors also suggest adding a little levity to the process. For example, include a trivia question on the back of some cards.
We really like the concept of the real-time random safety audit. Though we might by chance pick up some of the issues during patient safety walk rounds, the RSA is a method that is more focused and much more likely to encourage staff buy-in and foster development of a culture of safety. Look for more use of the RSA in the future.
Ursprung R, Gray J. Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis. Clinics in Perinatology 2010; 37(1): 141-165
Ursprung R, Gray JE, Edwards WH, et al. Real time patient safety audits: improving safety every day. Qual Saf Health Care 2005;14: 284-289