Patient Safety Tip of the Week


December 23, 2008        Why Safety Alerts Often Fail        





We have seen over and over again occurrence of incidents with adverse patient outcomes similar to incidents that had been the subject of safety alerts at other facilities. The story of neonatal heparin overdoses due to heparin flushing has been repeated multiple times on this website and many others. The lethal administration of concentrated KCl occurred at multiple hospitals before all eventually removed it from floor stock. Implantable devices get implanted into patients after a recall has been issued on those devices.


So how does your organization disseminate safety alerts? How do you ensure they get to the people who most need to see and understand them? How do you ensure that people who need to make changes are aware of the alerts and have taken appropriate steps to ensure those changes have been made?


Nursing Times (UK) reported this month (Patient safety alerts: Failing to reach the frontline) on interesting research done on implementation of patient safety alerts issued in the UK by the National Health Service. They found that alerts, though reliably reaching middle managers in the NHS system, were often not acted upon or were implemented suboptimally by frontline staff because of problems in how the alerts were distributed to or interpreted by frontline staff. They noted that two-thirds of the liaison officers they interviewed did not have clinical backgrounds and may not have understood the relevance of the alert. They also commented on the role of the title of the alerts. As an example, an alert including “needle-free intravascular connectors” in its title was often ignored by nurses who recognized these devices instead as “bioconnectors” or “bungs”.


We have, of course, seen the same thing here in the United States. Many organizations have no systematic approach to findng and identifying safety alerts. And in many organizations, the individual who may receive the safety alert has no clinical background and may not understand the significance or relevance of the alert nor rout it to all the appropriate individuals who need to see it.


In addition, the “Dear CEO” letter is often problematic. Most CEO’s do not have a clinical background. Logically, you would think they would discuss any such letters with their clinical leadership (Medical Director, Director of Nursing, Pharmacy Director, etc.). But, in reality, the CEO’s often rely on their administrative assistants to rout the letters to other individuals and the end result is often suboptimal. The “Dear CEO” letter that begins “you will be fined if…” usually gets their attention and improves routing to the appropriate individuals but very few letters include such threats.


Safety alerts may come from a variety of different sources, including:


We have long advocated that a standing agenda item at your organization’s monthly quality improvement committee meeting be “Alerts and Recalls”. Someone in the organization needs to be assigned the task of assembling these items, discussing their importance and targeted audiences with relevant organizational leaders (eg. medical director, director of nursing, director of pharmacy, director of environmental services, etc.), and ensuring they are sent to the appropriate people for action. Each month you need not only to note the new alerts you’ve identified but also to do a followup on the alerts you disseminated the previous month(s) and update the organization on the status of implemented changes. The quality improvement committee often has suggestions as to who else in the organization needs to be made aware of the alerts. You’d be surprised how often we hear comments like “oh yeah, unit X also keeps its own stock of Y…”.


The Nursing Times article noted above also mentions use of nursing “champions” to help improve awareness of certain alerts. They cite as an example use of nursing champions to improve awareness about a latex allergy alert that had been issued.


Jennifer Snyder and Laura Lindberg from Press Ganey Associates and Kim Judd from University Medical Center in Lubbock, Texas described a unique “safety coach” program in the September 2008 issue of Health & Hospital Networks. That program promotes two-way communication within the health system regarding safety issues. All units and departments have representatives in the program and they meet as a group monthly. Each safety coach is responsible for educating members of their unit or department on safety issues. In addition, they identify safety issues in their respective areas and report them back to the bigger group as part of a true “no-blame” safety culture. Reading this article is well worth your while because it is a great way to involve all your frontline staff in promoting patient safety. Use of such a system would be a good way to help you ensure that patient safety alerts get down to the people most likely to be involved in implementing change.



We didn’t mean above to exonerate the C-suite of its obligations in patient safety. Brief discussion of the status of such safety alerts should be part of the Executive Team’s daily or weekly meetings. Boards of Directors are surprisingly good at raising issues about alerts. Perhaps because they are usually mostly laypersons rather than clinical professionals, they often innocently say at a Board meeting “I read about X happening at a hospital. Could that happen here?”. It’s pretty embarrassing if you can’t tell them that you are already aware of that incident and your hospital has already addressed the issues involved.


You really want everyone in your organization to be aware of adverse events occurring elsewhere in healthcare and ask the question “I wonder if that could happen here?.


Alerts are most likely to be successful when they are:


Compare the Joint Commission Sentinel Event Alert we discussed last week Issue 42 - December 11, 2008: Safely implementing health information and converging technologies with an earlier Sentinel Event Alert Issue 33 - December 20, 2004: Patient controlled analgesia by proxy. The recent alert is loaded with great information and a host of important findings and recommendations. However, it is far too complicated to flow down to frontline staff and result in immediate changes. On the other hand, Alert #33 is far simpler. It is easy to read, straight to the point, focused on a single problem, and has several specific actions to take. Which of the two do you think is more likely to result in action being taken?


But we also need to be careful about the recommendations in alerts. All too often in recent years we have jumped on the bandwagon for actions felt likely to address a specific serious problem, only to find out later that our “solution” produced some unintended consequences that themselves resulted in patient harm. We’ll be discussing some examples in this column in the new year.





Patient safety alerts: Failing to reach the frontline. Nursing Times 2008; December 2, 2008


Developing a Safety Culture with Front-line Staff
By Laura Lindberg, Kim Judd, R.N., and Jennifer Snyder

Health & Hospital Networks. September 2008


Joint Commission. Sentinel Event Alert. Issue 33 - December 20, 2004: Patient controlled analgesia by proxy


Joint Commission. Sentinel Event Alert. Issue 42 - December 11, 2008: Safely implementing health information and converging technologies











Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive