Tips, Tools, and Techniques You Can Use in Your Patient Safety and Quality Improvement Initiatives. 

You my either scroll down through the entire Patient Safety Tip of the Week Archive or click on the headings at the right to go directly to the tip in a printer-ready format. Or click here to search the entire site.

February 26, 2007            Unintended Consequences

Those of you who are participating in IHI’s “5 Million Lives Campaign” likely are focusing on preventing harm from high-alert medications. If you are not, you should be – even if you are not officially participating in the campaign. One of the suggested changes to improve management of narcotics is to make available protocols and reversal agents that can be administered without additional physician orders. Given the frequency with which unintended respiratory depression (or other side effects) occurs secondary to narcotics, such protocols undoubtedly will prevent harm in almost every hospital or ambulatory surgery/procedure center.

However, we have now seen several cases where Narcan, administered by a nurse under such a protocol, actually precipitated an acute narcotic withdrawal syndrome. In each case, the patient had been on long-standing narcotic treatment (eg. for cancer-related pain) and had received an intravenous narcotic as part of conscious sedation for a procedure, resulting in respiratory depression. The Narcan administration was successful at reversal of the respiratory depression. However, the patients developed a very painful, uncomfortable state that was not immediately recognized as a withdrawal state.

The take-home lesson here is to build into your narcotic reversal protocol a provision for monitoring for an acute narcotic withdrawal syndrome in those patients who had previously been narcotic-dependent. The chance of this occurring is very small compared to the large number of patients who will benefit from a narcotic reversal protocol. But you need to keep this unintended consequence in mind as you develop those protocols at your facilities.

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March 5, 2007            Disabled Alarms

Ignoring alarms or intentionally disabling alarms is a topic we’ll revisit over and over (this is one of the “Big 3” root causes that can be found in many root cause analyses of cases with adverse outcomes).

However, we encountered an interesting case in which good intentions almost caused a disastrous outcome. The case was a “near-miss” in which a patient’s oxygen line had become disconnected from the wall source of oxygen. Mechanical ventilators often have an oxygen blender alarm. This is an alarm that is triggered by oxygen concentration falling below the prescribed level. In this particular case, the alarm failed to alert nursing staff that the oxygen content had dropped. At least one other monitoring system also failed to detect a drop in the patient’s O2 saturation. But fortunately the patient’s clinical condition was evaluated by staff and the problem remediated before any harm came to the patient.

In the course of the investigation, a piece of tape was found covering the blender alarm. The alarm, in fact, was functional. It was just not audible because of the tape. It was ultimately determined that during maintenance of the ventilators between use by patients, staff would test the ventilators with compressed air rather than oxygen (as a cost-saving measure). They would tape the blender alarm because it would go off when the compressed air was used instead of oxygen. The protocol used to assess alarms at set-up time for patient use did not include a specific assessment of the blender alarm. No other ventilators in use at this hospital were found to have tape over the blender alarm. However, when the potential issue was mentioned in an alert to other hospitals in this multi-hospital system, six other ventilators in use were found to have tape over the blender alarm!

The lesson learned in this case is that one should have a checklist-type routine for checking alarms immediately before a ventilator is used on a patient. And the checklist should be specific for the ventilator being used. It is not at all uncommon for a hospital to have multiple different models of ventilators and some may have alarms that others do not. Therefore, your protocol should include not only checking those alarms that are on all ventilators but also those that may be specific to the unit being used.

Frankly, this ultimately comes back to a design issue as a root cause. Good design principles would have led to an automated alarm testing protocol that would have to be carried out before a unit could be used in patient care.

The second lesson is also obvious – when you find a disabled alarm, don’t jump and take punitive action on the individual who disabled the alarm. Continue your root cause analysis and you’ll always find some other root cause that led them to disable the alarm and that other staff are likely also disabling such alarms.

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March 12, 2007    10x Overdoses

A number of erroneous processes have been involved in causing inadvertent administration of 10 times the intended dosage of medications. Probably the most common and dangerous error is the use of the abbreviation “U” for unit. Fatal overdoses of insulin have been given when a “U” written by provider is misinterpreted as a “0”. That is a primary reason that “U” is one of the items on the Never Use These Abbreviations list from ISMP. Your hospital should not only have a policy of which abbreviations can and cannot be used but also an audit process to ensure that the policy is being complied with. Keep in mind that such abbreviations should not only be excluded from orders, but they should not appear anywhere – not in progress notes, H&P’s, consultations, discharge summaries, etc.

The second common scenario leading to tenfold medication overdoses is use of a trailing zero in order writing. When writing, for example “2.0 mg”, the transcriber may miss the decimal point and see “20 mg”. This especially tends to be problematic if your facility accepts faxed orders (your facility should have a policy specifying how faxed orders will be accepted and under what circumstances they will be rejected). As above, make sure you audit charts to make sure trailing zeroes are not being used in your facility.

A third cause of tenfold overdoses is when the last letter of the drug ordered ends in a letter that can look like a “1”. Typically this is an “L”, as in Tegretol. This occurs when there is little space between the last letter and the subsequent dosage.

Yet another cause is another unintended consequence, this time the result of technology. As we’ve move to computerized order entry we’ve improved upon many of the handwriting errors that led to incorrect medication administration in the past. However, the technology has introduced new types of errors. The data entry person may double press a key (or the key may become stuck) resulting in, for example, “88” instead of “8”. Also, during data entry it is possible to think one hit a decimal point but it fails to print out. Such data entry errors may occur with any type of keyboard but we find them especially likely to occur when using handheld devices with small keyboards or styli for input. These types of data entry error have recently been noted in programmable intravenous infusion pumps and there have been several occurrences of 10x overdoses with those pumps. Therefore, a policy of having a second independent observer verify the dosage or rate on such pumps makes sense (however, keep in mind that error rates from other industries tell us that one who oversees someone else’s work typically does so in error up to 10% of the time!).

It is almost inevitable that at some time in your facility such an order for 10x the intended dose will be written or entered. It is therefore especially important that you have appropriate second line defenses to capture such errors before they reach the patient. Examples are computerized pharmacy systems that flag doses falling outside “usual” ranges.

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March 19, 2007

Put that machine back the way you found it!

Most often a cascade of errors, rather than a single error, is necessary before patients actually suffer harm. When we do a root cause analysis, it is usually painfully apparent that avoiding any one of the errors in that cascade would likely have prevented the adverse patient outcome.

A dialysis patient was admitted via the emergency room to an acute psychiatric service because of abnormal behavior. He later suffered a cardiac arrest, precipitated by hyperkalemia. The RCA revealed multiple issues (delay in lab specimens being processed, poor panic value communication, poor communication between the psychiatry service and medical consultants, etc.). The EKG which had been obtained in the ER did show peaked T-waves highly characteristic of hyperkalemia. However, these were not readily recognized because that EKG had been run at ½ voltage/sensitivity unintentionally. The EKG machine had been used on other patients and during its previous use the ½ voltage/sensitivity was used. The technician running the EKG on the new patient did not recognize that the EKG was at ½ voltage/sensitivity and, though the scale was clearly marked at the beginning of the EKG, one would not realize that on rapid perusal of the strip. Several other patients had EKG’s with the reduced voltage/sensitivity but none were impacted by the EKG findings. This is an example of a latent error coming together with several more acute errors to result in adverse patient outcome.

At your facility, how is the EKG voltage/sensitivity recorded on the EKG? If the scale is indicated, is it indicated on each segment or is it just at the beginning of what might be a long EKG strip? Do the EKG machines revert to full voltage/sensitivity after each use? Do they require manual reversion or is the process automatic? If you are like most hospitals, you probably have EKG machines of varied ages. Some may automatically reset to standard voltage recording but others may not. Do you have a policy (and appropriate training and audit) to ensure that those requiring manual reset get reset immediately after each use?

Obviously, this comes back to a design issue. The optimal design would clearly delineate the voltage/sensitivity on all segments but would also automatically revert the voltage/sensitivity back to standard after each use.

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March 26, 2007

Alarms Should Point to the Problem

An ESRD patient was having his regularly scheduled dialysis session. Since he would be in the dialysis center for several hours, he was in a comfortable lounge chair that tipped back. Also, since it was somewhat cool, he was offered a blanket to keep warm.

Midway through the dialysis session, the low-pressure alarm rang. The nurse turned off the alarm and eyeballed the patient and saw no blood. Nothing further was done. Soon thereafter the low pressure alarm triggered again. This time it was recognized that the dialysis catheter had become dislodged and the patient had, in fact, had considerable blood loss. It had not been appreciated immediately because the blanket had been covering up the catheter site and the blood, rather than being visible on the floor, had been pooling in the webbing of the lounge chair.

Anyone who has ever spent time in an ICU or other hi tech medical environment knows that the usual response to an alarm is to turn the alarm off. Proper design of medical equipment therefore should force the responder to focus on the source of the problem. In the case at hand, the equipment and alarm were on the side of the patient opposite from the involved limb so that the visual attention of the responder was not directed immediately to the site the alarm was drawing attention to.

My copy machine tells me exactly where to look when there is a paper jam. Why can’t critical medical monitoring devices do the same thing?!!! Proper design of medical equipment necessitates seeing how humans will respond to it in the typical medical setting. When Microsoft develops new software, it puts real people in a real-life setting and sees exactly how people are likely to respond to various scenarios. Why can’t all medical device manufacturers learn from this?

Unfortunately, you all have lots of equipment that have alarms that don’t make the responder focus directly at the problem. Faulty response to alarms is one of the “big 3” problems encountered in many root cause analyses of sentinel events. Performing FMEA (Failure Mode and Effect Analysis) is a good way to help anticipate events that might arise in your critical settings.

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April 2, 2007

More Alarm Issues

A patient with asthma arrived mid-morning at an emergency room with status asthmaticus. Treatment was begun but the patient required intubation and mechanical ventilation. He was stabilized and the ICU was called to admit the patient. The ICU had no empty beds but told the ER that they expected a bed to open up shortly. The ER said the patient could stay on a ventilator in an ER room until that bed was ready. Respiratory Therapy evaluated the patient and hooked the patient up to a dual power-source portable ventilator. That was felt to be ideal for this patient because it could be used either with typical AC current in the ER or use its built in battery during transport.

A call to the ICU after an hour still found no available ICU bed. The ER now started getting busier but the patient remained stable on the portable ventilator. Unbeknownst to all, the circuit breaker on the AC wall source had tripped, so the portable ventilator was running on battery power. After 5 hours in the ER, the portable ventilator exhausted its battery power and ceased functioning. The patient had a respiratory and then cardiac arrest.

Investigation revealed that no staff had heard any alarms on the EKG monitor even though it was likely the patient would have developed tachycardia and/or bradycardia after the ventilator had ceased functioning. The alarm volume, in fact, had been turned down to a level barely audible even by those in the immediate room. The room was immediately adjacent to the nursing and secretarial work area and staff had turned down the alarm volume because it distracted them from work.

When the hospital team conducting the RCA investigation came to the ER to re-enact the events, they found that the volume on the same alarms had been turned down again. A similar visit done with the health department a week later again found the alarm volume turned down.

Avoiding the snap reaction to take punitive action against the staff member who had initially turned down the alarm volume, it became very clear that the root cause was a flawed design to the ER. That design obviously led to the practice of turning down the alarm volume. One wonders how many ER’s, ICU’s, etc. suffer from this same type of design flaw that promotes such an unsafe practice. I’m always amazed when a hospital administrator proudly states “we designed this unit to have full visual contact of all patients”, only to find that the very proximity led to this practice of lowering alarm volumes.

A second root cause was the development of a “culture” in the ER that tolerated manipulation of the alarms as an unsafe workaround.

Another root cause was in the design of the portable ventilator. How was one to know that it was functioning on battery power rather than AC power from the wall outlet? In fact, it did have an indicator light to flag which power source was being utilized. However, that indicator light was located on the back of the unit and not readily visible to staff in the room.

The case is also a good example of how technological “safety” advances may not actually reduce accidents, much like maritime radar simply encouraged ships to go faster. In this case, the “ideal” dual power-source ventilator fostered a false sense of security.

Lastly, the bottleneck caused by bed unavailability in the ICU was yet another root cause that led to implementation of a better system for triage of ICU beds.

A very unfortunate case but it illustrates multiple points that one often sees in cases with adverse outcomes (cascade of errors, latent errors, violations, unsafe workarounds, communication breakdowns, misuse of alarm systems, multiple design flaws, safety “culture” issues, bottlenecks and patient flow issues, and technological advances with unintended consequences).

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April 9, 2007

Make Your Surgical Timeouts More Useful

We’ve often heard surgeons complain that they “waste” a lot of time doing surgical timeouts to prevent events that are very rare to start with. In fact, you can use surgical timeouts (either the pre-surgical timeout and/or the final verification timeout) to also focus on what are more common complications you wish to avoid. For example, use the timeout to ask questions such as following:

1. Is this patient getting prophylactic antibiotics? Who is giving them? When?
2. Is this patient a candidate for perioperative beta blockers? Did he get them?
3. Is this patient a candidate for DVT prophylaxis? Will it begin intraoperatively?
4. Will this patient need repositioning to avoid nerve compression or decubitus? If so, when?

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Important update: See November 20, 2007 Patient Safety Tip of the Week "New Evidence Questions Perioperative Beta Blocker Use"

April 16, 2007                     Falls with Injury

Falls with injury occur in virtually all health care settings. Some excellent resources are available to help institutions reduce the risk of harm to their patients from falls: IHI (The Institute for Healthcare Improvement),  the VA National Center for Patient Safety, the Health Care Association of New Jersey, to mention just a few.

The Institute for Healthcare Improvement also has an upcoming web-based initiative to help organizations reduce harm from falls .

Having reviewed numerous reports and RCA’s involving falls with injury, we have a couple observations that merit discussion. First is that, though most hospitals/facilities use some sort of fall risk assessment tool, these are often only used on admission to the facility. It is not uncommon for a patients to have a low risk for falls on admission, only to have multiple factors change during the hospitalization that now make them fall-prone. It is therefore imperative that any fall prevention program have built-in flags that trigger reassessment for fall risk.

Our second observation is that the initial medical responder to a patient who has fallen often has a focus much different from that of a quality improvement professional. That responder typically is most concerned with whether any injury has resulted from the fall. Ascertaining the reason for the fall is often only an afterthought and often neglected all together. And, sometimes, the only clue to the cause of the fall can be found only around the time of the fall (for example, orthostatic hypotension may no longer be present a day or so later when someone finally gets around to looking for it). The initial responder is often a housestaff member who has little knowledge about the patient prior to the fall. And we have not done a particularly good job of educating housestaff on how to perform a good post-fall assessment. Therefore, facilities should build protocols and checklists for housestaff (or other first medical responders) to utilize in their post-fall assessment. Several good tools for post-fall assessment are available (see references above).

Now that we’ve mentioned orthostatic hypotension, it is most notable that orthostatic signs are very seldom actually checked by the medical responder to a fall. Even when they are checked, they are often inadequately assessed. The proper technique for checking orthostatic signs is as follows:

First, have the patient lie supine for at least 5 minutes prior to beginning measurements (this is because many of the neurological causes of orthostatic hypotension are associated with supine hypertension, so one is most interested in the magnitude of the orthostatic change rather than just in the absolute standing blood pressure). One should then measure both the blood pressure and pulse of the patient in the supine position. Then, after telling the patient what you will be doing and asking him to tell you about symptoms such as dizziness or graying out of vision that might occur when upright, one stands the patient upright (being sure you can safely lie him down if they do become symptomatic!). The pulse should be measured first on standing, since what the heart rate does in response to orthostatic hypotension may provide clues to the etiology of orthostatic hypotension. The blood pressure is then recorded. If there is a drop in blood pressure, one should keep the patient upright (unless symptomatic) and record the blood pressure and pulse again at 1-2 minutes intervals until it has stabilized.

Sorry for the digression! But we find this one of the simplest, yet most neglected, parts of the physical examination in the post-fall patient.

Lastly, food for thought: How many of you have had osteoporosis screening? If you did, how many had a fall-risk assessment? Not many, we’ll bet! Isn’t the goal of osteoporosis screening to prevent fractures? Wouldn’t it be wise to incorporate a fall-risk assessment (and education) any time someone is sent for osteoporosis screening? Sounds like an opportunity for providers, quality improvement professionals, and third-party payors to all climb on board.

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April 23, 2007             Predictable Errors

Some errors are predictable. The classic example given is people writing checks in January dated for the previous year. Banks had to alter their usual time limitation for cashing checks to take into account this predictable error. Some errors in medicine are also predictable.

One type of predictable error in medicine we call the “two in a box” phenomenon. Assume there are 2 items (A and B) in a box or some other sort of container. You are looking for item A. You reach into the box and pull out B. Many people put B back in the box and pull out the other item, assuming it is A without checking its identity. That’s human nature. But what happens if your assumption was wrong (i.e. that the items in the box were different items and that an A was even in the box)? Suppose the “box” was a refrigerator with 2 units of blood in it. You’ve now pulled out a unit of blood that may be inappropriate for your patient. You say that’s why you have a double check built into your blood products policy? That may help you in that particular circumstance but keep in mind that we know from industry in general that the error rate for someone who checks someone else’s work may be as high as 10%!

Think of what circumstances you might find this “two in a box” problem in your facility. We have seen the following examples of this phenomenon in medicine events with adverse outcomes:

• Drugs in a drawer
• RBC’s in a refrigerator
• Dials on a control panel
• Isotopes in a transport container
• Heart valves in a refrigerator
• Ocular implants in a bag
• Remote telemetry transmitters for 2 different patients

So next time you are making safety walk rounds in your facility, take a look to see how often you come across this potential “two in a box” scenario. You’ll be surprised how often you find it.

When there is an untoward incident, the person who failed to check the item often gets reprimanded or punished in some other way. But it should be clear that this is a system design problem that set up that individual (and potentially many others) to do exactly what they did. So make sure your systems are designed to avoid putting anyone in the “two in a box” scenario.

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May 1, 2007

The Missed Cancer

Everyone’s worst nightmare is identifying a possible cancer yet the patient not being made aware and getting prompt attention when the cancer might be at a treatable stage. Lots of examples are available:

• The lost Pap smear
• The CXR report that never made the chart before discharge
• The lab report that got filed in the wrong chart

How can we prevent these sorts of disasters? Communication at multiple levels is critical (lab/hospital, physician/practice/outpatient clinic, patient/family). And you need systems to help you.

At the hospital level, several things can be done. First is putting in place a system to ensure notification of practitioners of any unexpected findings (eg. a suspicious lesion seen on a radiograph ordered for other purposes). It is not uncommon these days for patients to be discharged from the hospital before the final radiology report hits the chart. So one must assume that such a finding could be overlooked, even if the hospital sends copies of all reports to the physician office as well. Such a system requires setting up a log (paper or electronic) to confirm that the practitioner was contacted by the radiologist to notify him/her of the suspicious finding. The “case” is not closed until that conversation has taken place. There are examples in the literature of successful implementation of such systems.

Also, the hospital discharge summary should always include a section for “tests done but official reports pending” so that the practitioner following up the patient is alerted to the fact not all reports were final at discharge.

At the physician/practice level, you need a system to track results of all tests ordered. A paper-based tracking system is theoretically possible but not practical for most practices. Technology provides the best solutions. However, you don’t need an expensive electronic medical record. A simple Excel spreadsheet or Access database will do. Simply set it up with the patient name (and a second identifier so you don’t mistakenly mix up 2 patients!) and a column/field for tests pending and one for date ordered. You could also have a column for the date you contacted the patient with the results. You simply then sort your list each day by the “tests pending” field so you can follow up on reports that should have been received but have not yet been received. You then remove the test from the test result pending field as the result comes in. You can have a similar system on your handheld PDA but make sure you take appropriate measures to safeguard patient health information.

Also, when the paper reports come in to the office, they should not be filed until the practitioner has indicated (usually by initialing the report) that he/she has read the report.

At both the hospital and practice levels, make sure you perform periodic audits to ensure that the process you set up is indeed effective.

Lastly, as a patient, never assume that no news is good news. Any time you have a test done, ask your physician when and how the results will be communicated to you. And if you have not heard the results within a reasonable period of time, contact your physician to find out the result.

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May 8, 2007 

“Doctor, when do I get this red rubber hose removed?”

One of my most embarrassing moments as a young neurologist was when, as I was providing inpatient discharge instructions to a young multiple sclerosis patient, she asked the above question. It caught me totally by surprise that she had a Foley catheter in place. Later, when I first became involved in quality improvement, unnecessary Foley catheters became one of my pet peeves. You would be amazed at how often the Foley catheter appears unbeknownst to the primary physician responsible for the patient’s care and how often they are placed without legitimate medical indication. They often get put in for measuring I&O, for incontinence, or for convenience. Very often they are put in either in the emergency room or perioperatively or ordered by a covering physician who will never see that patient again. So years ago, we established “catheter rounds” and began putting a brightly-colored sticker on the order sheets of all patients with a Foley catheter, requiring the physician to indicate the reason for the Foley catheter and the expected duration of its use. Catheter use dropped about 50%!

It’s no laughing matter. Nosocomial UTI’s, still the most common nosocomial infection, are not only a safety issue for patients but they are also very costly to hospitals. The average additional cost for patients who develop nosocomial UTI’s is about $2000 due to increased length of stay and increased antibiotic and supply needs. So establishing systems to prevent unnecessary Foley use is not only good for your patient safety program, it is also very cost-effective.

The system you put in place can be low-tech or hi-tech. The simple colored sticker alert mentioned above was very effective. Adding lines for indication and duration to pre-printed order sheets can also be effective. For those facilities fortunate enough to have computerized physician order entry, add a new pop-up screen with these questions any time someone orders a Foley catheter.

Beware of unintended consequences, though. Your policy should not be so restrictive that patients who truly do need a Foley catheter are made uncomfortable. Alternatives to Foley catheters may include condom catheters or intermittent catheterization.

Also, be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time.

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May 15, 2007

Communication, Hearback and Other Lessons from Aviation

Analogies between the aviation industry and healthcare are well-known in patient safety circles. The types of problems encountered in aviation accident investigations are eerily similar to those encountered in root cause analyses of adverse events in healthcare. One exercise we recommend is reading some of the detailed investigation reports available through the NTSB (National Transportation Safety Board). As you read them, you can usually visualize a situation in healthcare in which almost identical issues occur.

A good case to start on is the investigation of the Avianca Airlines flight from Medellin, Columbia to JFK airport in New York in 1990. Multiple factors and events cascaded to result in this fatal crash, similar to the typical cascade seen in healthcare incidents. However, this investigation illustrates several of the key communication problems encountered in either an aviation or healthcare setting. It is an excellent example of both “language” and “lingo” problems and also shows how non-content verbal features can play a role in context.

Basically, the plane ran out of fuel after weather and air traffic led to a prolonged holding pattern and an unsuccessful approach to JFK. Though an issue with fuel was noted on several occasions in conversations between the cockpit crew and air traffic control, the urgency of that fuel shortage was never properly conveyed in the verbal interactions. Some of the issues had to do with the “language” barrier (the pilot spoke little English and communicated primarily via the first officer). Others had to do with different interpretations of the word “priority”, the air crew apparently thinking it meant emergency but the air traffic controllers not appreciating that specific term as meaning an emergency situation existed. One might even speculate from occasional small talk and occasional laughter in the cockpit whether “priority” being taken in the appropriate context by all involved.

The team approach to training known as Cockpit Resource Management (CRM) training is now used not only in the airline industry but is being used to improve teamwork in healthcare as well. Important communication techniques, such as hearback, are used to ensure that all members of the healthcare team clearly understand the intent and urgency of specific verbal communications. Simulation is another technique borrowed from aviation and used by healthcare teams to look at how teams communicate and respond in scenarios such as the operating room or emergency room. Loudness, intonation, and body language are also important determinants of effective communication. We highly recommend organizations serious about patient safety consider investing time and resources in training their various teams using CRM or simulation training. Also, a lot can be learned from simply recording or videotaping an operating room session and then having all relevant parties sit down and constructively critique their communication and team interactions.

Another good program for team training is TeamSTEPPS™, developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ).

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May 22, 2007    

More on TeamSTEPPS™

Last week, in our discussion on cockpit resource management and teamwork training, we noted the TeamSTEPPS™ program as a good resource. It is a team training program developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ).

This week we had a first-hand opportunity to see the program and its potential. TeamSTEPPS™ was presented at the New York State Department of Health’s annual Patient Safety Conference in Albany, cosponsored by HANYS and GNYHA. Heidi King, the Deputy Director for the Department of Defense Patient Safety Program, provided an overview of development of the program. Key experts in teamwork from multiple fields came together and used evidence-based and research-grounded principles to develop the tools needed for teamwork training. This program and the tools have now been rolled out in multiple healthcare settings and applied to multiple subsites and patient populations and multiple different teams. The program comes with recommended rollout and implementation strategies but is eminently customizable to any organization. The program is continuously updated. Tools for outcomes measurement are also available.

Best yet, the tools are available for free! The TeamSTEPPS™ resources include presentation modules, great videos of bad and good team interactions and communications, implementation and action planning tools, evaluation tools, a pocket guide and posters. Many of the resources are available online and others are provided on CD/DVD’s. Topics covered include developing teams, use of briefs, brief checklists, huddles, debriefing, situation monitoring, cross monitoring, SBAR, handoffs, and others.

We highly recommend this program. It can be implemented at the individual unit level or overall organizational level. It has even been used as a community-wide collaborative effort. Programs like this should be part of the core curriculum for medical schools, nursing schools, and other healthcare professional schools. It clearly demonstrates the importance of multidisciplinary interaction and team skills that are necessary for the delivery of safe, effective care.

Learn more about the program by going to the TeamSTEPPS™ web page at AHRQ or the Department of Defense Patient Safety website.

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May 29, 2007

Read Anything & Everything Written by Malcolm Gladwell!

We had not planned to do a Tip of the Week over this holiday weekend. However, our “light” reading over the holiday was “Blink” by Malcolm Gladwell, who also authored “The Tipping Point”. Of course, there is nothing really “light” about Gladwell’s books other than that he has an uncanny ability to present really profound ideas in such a smooth read that you don’t put his books down. He’s a master at telling stories to illustrate concepts well-founded in scientific research.

For those who do root cause analyses (RCA’s), “Blink” provides great insight into how decisions are made. In many RCA’s your goal is to find out why people made the decisions they made since others are also likely to use the same decision making processes in the future. The first premise of “Blink” is that decisions made quickly can often be as good or better than those requiring much more deliberation. This “rapid cognition” is really done at a subconscious level. You might refer to it as your “gut feeling” or “instincts” and you may not be able to explain well why you came to that decision but such decisions were probably processed very methodically by the subconscious brain. 

However, there are experiential influences that may bias that rapid decision making and there are other influences that may interfere with rapid cognition. Knowing what circumstances are likely to cause those influences on rapid cognition may be very helpful in planning with patient safety in mind. For instance, knowing what scenarios are likely to lead to deleterious rapid decisions can help design effective training on avoidance of such decisions. Likewise, understanding when too much information interferes with rapid cognition can be important in design of clinical processes. Most of the best solutions to patient safety problems involve simplification rather than adding more steps to processes.

An example of rapid cognition leading to a bad outcome is the high-speed chase, which leads to predictable behaviors by both the pursuer and the one being chased. Training to recognize the “high-speed chase” syndrome might help avoid those chases ending in bad outcomes. Gladwell describes how under extreme stress a typical reaction is tunnel vision, diminished awareness of sound, and sense that time has slowed down. That leads to extreme focus on an immediate problem and a lack of awareness of the surroundings. While this may enhance performance in dealing with certain problems, it may foster snap judgements that are detrimental in others. He goes on to describe a problem in Florida where police were involved in high numbers of violent incidents with citizens. Observers were placed in squad cars to monitor police behavior. They found that the police officers did very well when they were face-to-face with suspects but did a poor job in their approach to the scene. So the department focused on what the officers did before they approached the suspect and the number of violent incidents dropped substantially. Clinical analogies obviously exist in multiple hi-risk environments, like the OR or ER or ICU.

There is even a chapter on the importance of facial expression in communication. Makes you wonder how we ever manage to get it right with all those masked people in the OR!

So no specific “Tip” this week other than that you’ll be both fully amused and stimulated by reading Gladwell’s “Blink”. Our bet is that during your next RCA you’ll find yourself saying “Now I know why they did that!”.

Print Read Anything & Everything Written by Malcolm Gladwell!

Update: See Our May 27, 2008 Patient Safety Tip of the Week "If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work"

June 5, 2007    

Patient Safety in Ambulatory Surgery

We frequently see hospital systems focus the bulk of their patient safety activity on the inpatient side. Historically, there have always been fewer serious adverse events in the ambulatory surgery suite, whether hospital-based or free-standing, than in acute care hospital operating rooms. This, of course, largely reflects the relatively good overall health of the patient population and the fact that procedures are generally less complex than those done in acute care settings. Nevertheless, serious incidents can occur in ambulatory surgery settings and there are certain factors unique to these settings that may predispose to certain kinds of error. In fact, more than half of the wrong-site surgeries reported to Joint Commission have occurred in ambulatory surgery sites.

One factor is that a surgeon will often be performing many cases of the same or similar procedures. Interestingly, very experienced surgeons may be more likely to be involved in wrong-site cases, perhaps because their experience allows them to schedule so many cases in one day.

The quality of the medical records is often not as good in ambulatory settings. The “facility” medical record is often scant and the physician often brings in his/her office notes that are “unofficial” as far as the facility is concerned. Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure.

Another practice that should be frowned upon is allowing the medical records of multiple patients to be in the operating room. We’ve seen instances where a surgeon might bring in a stack of office charts on all the patients on that day’s ambulatory schedule. The system should never allow one to mistakenly pick up the chart of the wrong patient during a procedure. The same applies to other things a physician might bring in for all the day’s patients (eg. X-rays, scans, implants, etc.). The rule should be that all the things in the OR apply to only the patient on the table.

And there are certain production pressures unique to the ambulatory setting. When a surgeon is booked for many cases in one day, there is a higher likelihood of last-minute changes in the schedule. Also, we’ve seen cases in the ambulatory setting where one patient may demand a procedure earlier in the day, leading to last-minute alterations in the order on the schedule. And lastly, the pressure to get cases done promptly and stay on schedule are everpresent.

Remember that all elements of the Joint Commission Universal Protocol apply equally to the ambulatory setting. And keep in mind that the verification process must take place at multiple points preoperatively, including at the time the procedure is scheduled.

Availability of all appropriate documents at the “timeout” is essential. They should be reviewed for actual content rather than simply acknowledging their presence and there should be agreement by all on what the documents say rather than simply having individual review of the documents. And, of course, good communication among all team members, utilization of hearback, requiring agreement of all team members before proceding, and involvement of the patient and/or family are all important in ensuring safe outcomes.

Organizations should utilize some of the resources available for patient safety in the ambulatory surgery setting. The American Academy of Ophthalmology has issued good guidance statements on avoiding wrong-site surgery  and avoiding incorrect intraocular lens placement , with good examples of how checklists might be utilized. And the American Academy of Orthopedic Surgeons also has very good resources.

Overall compliance with the “timeout” requirements of Joint Commission’s patient safety goals for ambulatory surgery is still only in the 80% range so organizations should take a hard look there.

Joint Commission is also finding less than full compliance in ambulatory surgery on several medication-related goals (eg. medication reconciliation, labeling medications and solutions, “do not use” abbreviations, and look-alike/sound-alike drugs). We’ll address some of those issues in future Tips of the Week.

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June 12, 2007    

Medication-Related Issues in Ambulatory Surgery

Many have asked why all Joint Commission’s patient safety goals should apply to ambulatory surgery sites. After all, the patient is only there for a matter of hours and then goes home. Right? Why should we have to jump through all sorts of hoops for something that really doesn’t pertain to us? We are only here to do this one procedure and what do we know, anyway, about all those other medical problems the patient has.

Well, you have to remember that ambulatory surgery is a part of a larger healthcare continuum and events related to ambulatory surgery can be reflected in other parts of that continuum. Let’s look at an example. Last week we mentioned that medical records are often a problem in ambulatory surgery sites. A patient came to an ambulatory surgery site for a procedure. Very little history had been provided prior to the patient’s arrival so on the day of the procedure staff asked the physician’s office to fax over some relevant office notes and the medication sheet. While hospitals have clearly begun to comply with the “do not use” abbreviation lists, most physician office notes are still replete with such abbreviations. The faxed notes were included in the facility medical record. The surgical procedure went well and the patient went home without incident or complication. However, 2 weeks later she was seen in the ER of the same hospital system for an unrelated problem. The patient’s primary physician was not available. The ER physician found in the patient chart copies of those office records that had been faxed in to the ambulatory surgery site. One of the medications listed in those records had a “qd” abbreviation that, perhaps in part because of fax artifact, looked like “qid”. The patient was admitted from the ER to the hospital and her maintenance medication that had been intended to be given once daily was now actually give four times daily. The error was not discovered until the patient developed symptoms of drug toxicity 5 days later. Well-performed medication reconciliation and compliance with the “do not use” list goal could have prevented this adverse outcome. But the case nicely illustrates how events in one part of the system can effect events in another part.

Medication reconciliation is also critical before and after ambulatory surgery. It is critical that a full list of the patient’s medications, including OTC drugs and herbal remedies, be reviewed before the procedure. Several of these might predispose the patient to bleeding problems, for example. And one especially needs to know when the last dose of medication prior to arrival for the procedure was taken. This is especially relevant for medications such as insulin and ties together with orders for the patient to be “nothing by mouth” for a period prior to surgery. Similarly, it can be anticipated that on discharge from ambulatory surgery the patient is likely to receive some new drugs, for example analgesics and perhaps and antiemetic. One needs to be sure there is not likely to be a drug-drug interaction with the patient’s current medications.

Last week we noted that Joint Commission is finding less than full compliance in ambulatory surgery on several medication-related goals (eg. medication reconciliation, labeling medications and solutions, “do not use” abbreviations, and look-alike/sound-alike drugs). Today’s tip illustrates why at least 2 of those goals are important in ambulatory surgery patient safety. We’ll talk about labeling medications and solutions and look-alike/sound-alike drugs in future tips.

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June 19, 2007    

Unintended Consequences of Technological Solutions

In our April 2, 2007 Tip of the Week we showed an example about how a technological advance (a dual-power source portable ventilator) gave rise to an unintended consequence. It is not at all uncommon for technological advances to create some new unintended consequences.

In the early days of telemetry, hospitals realized they could now utilize remote telemetry to free up valuable ICU beds. A hospital purchased such a remote telemetry system in which the transmitter could be placed on a patient on one floor of a hospital and the receiver/monitor was in the CCU as part of a bank of telemetry screens that were continuously viewed by a nurse assigned to that duty. One day, right around nursing change of shift, two patients were admitted to the remote floor and telemetry was ordered on both. The nurse took two transmitters with him and hooked the patients up, then called the CCU monitoring nurse to tell her about the two patients just hooked up. About an hour later the CCU monitoring nurse called the remote floor because one of the patients was in ventricular fibrillation. A code was called and the floor staff and code team ran to the patient’s room, only to find him sitting in bed, watching TV and eating a meal. Only after several minutes of fiddling with his EKG leads and talking to the nurse in the CCU did anyone realize that the patient several rooms down the hall was really the one in ventricular fibrillation. The transmitters obviously had been transposed! This is a variation of the “two in a box” phenomenon we talked about in the April 23, 2007 Tip of the Week. And, of course, the system was poorly designed in that it allowed the first nurse to take out two remote telemetry transmitters at the same time. However, we are presenting it here as an example of how a technological solution expected to enhance patient safety actually created a new unintended problem.

Another example was when a hospital purchased a new alarm system that would send an alarm when the patient got out of bed. It turned out that on some units there were not enough electrical outlets for both the new bed alarms and the nurse call buttons. So a decision was made in some cases to swap out these two devices. You can guess what happened: nursing staff responded to the “out-of-bed” alarm only to find the patient lying on the floor with an injury because he tried to get out of bed after no one responded when he pushed the nurse call button!

And there are lots of examples of unintended consequences associated with CPOE (computerized physician order entry). The classic example is correction of the illegible  handwriting problem but introduction of  the “cursor error” or “stylus error” in which the physician inadvertently chooses a medication above or below the one he/she actually intended to choose on the computer or PDA screen. The last issue of ISMP’s newsletter had an example of a nonventilated patient inadvertently being given a paralytic agent, in part because the ordering physician was entering orders from a remote site and accidentally ordered this for the wrong patient.

We present these cases not to discourage use of technology, which is one of our most potent weapons in the patient safety arsenal, but rather to remind all that any solution (whether technological or instituting a new approach, etc.) may give rise to unintended consequences. Sometimes they can be anticipated, other times they cannot. Either way, careful vigilance for unintended consequences is necessary.

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June 26, 2007            Pneumonia in the Stroke Patient

Much of the morbidity and mortality in patients with acute stroke is related not just directly to the neurological deficit but rather to the complications that occur, many of which are potentially preventable. Those complications include decubiti, falls, DVT, UTI and pneumonia. Preventing these complications is good not only from a patient perspective but very important in avoiding unnecessary costs for the hospital. Most hospitals already incorporate risk assessments for decubiti, falls, and DVT into their nursing care plans and clinical pathways. In our May 8, 2007 Tip of the Week, we talked about how inappropriate use of Foley catheters causes many nosocomial UTI’s.

A paper in the last issue of the journal Neurology highlighted the human and financial impact of pneumonia in the acute stroke patient¹. The occurrence of pneumonia was associated with about $15,000 incremental cost per case. Previous work by the same group showed that pneumonia increased the risk of dying within 30 days threefold in patients with acute stroke, after correction for severity of the stroke².

The incidence of pneumonia in the acute stroke population varies considerably in the literature, largely because of stroke populations of varying severity and differences in definitions used. However, studies that have looked at stroke patients having at least some degree of paralysis present have noted incidences of pneumonia typically in the 12-13% range^3,7.

Two of the most important factors in the stroke patient predisposing them to pneumonia are impaired swallowing ability and impaired cough reflex. There is currently no single “gold standard” for swallowing assessment and different hospitals may use different methods⁴. Some have suggested formal assessment of the cough reflex may be even more important⁵, though this has not been done at most facilities. The current standard of care is that all patients with acute stroke should have an assessment of their ability to swallow prior to being fed food or fluids orally. That assessment is one of the measures used in Joint Commission’s accreditation program for stroke centers⁶. Quite frankly, it should be a measure routinely followed in the quality improvement program of any hospital that cares for acute stroke patients, regardless of whether the hospital has stroke center designation.

Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half⁷. Some hospitals have the swallowing assessment done by nursing staff, others by speech therapy. Others may have nursing do a screening assessment, with speech therapy doing a more formal assessment only in abnormal cases. There are preliminary reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols^8,9.

Given the relatively low cost of implementing a dysphagia screening program for all stroke patients, a savings of $15,000 for each pneumonia prevented is an excellent return on investment. Again, this is another good example of how good patient safety programs can be very cost-effective for most hospitals.

1. Katzan IL, Dawson NV, Thomas CL, Votruba ME Cebul RD. The cost of pneumonia after acute stroke. Neurology 2007; 68:1938-1943
2. Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology 2003; 60:620-625
3. Aslanyan S, Weir CJ, Diener H-C, Kaste M, Lees KR. Pneumonia and urinary tract infection after acute ischaemic stroke: a tertiary analysis of the GAIN international trial. Eur J Neurology 2004; 11: 49-53
4. ECRI Investigators. Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients. AHRQ 1999.
5. Addington RW, Stephens RE, Gilliland KA. Assessing the Laryngeal Cough Reflex and the Risk of Developing Pneumonia After Stroke: An Interhospital Comparison. Stroke, 1999; 30: 1203-1207
6. Joint Commission, Primary Stroke Center Standardized Stroke Measure Set
7. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal Dysphagia Screening Protocols Prevent Pneumonia. Stroke 2005; 36: 1972-1976
8. Hinchey JA, Shephard TJ, Tonn S, Ruthazer R. Preprinted Orders Are Associated With High Adherence to Processes Required on Admission: P468. Stroke 2006; 37: 739
9. Book DS, Dostai J, Sama D. Compliance with Written Care Protocols Predicts Success in Achieving JCAHO Stroke Performance Measures: P469. Stroke 2006; 37: 739

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