What’s New in the Patient Safety World

July 2012



·        WHO Safe Childbirth Checklist

·        Progress on Swallowing Testing in Stroke

·        VA Checklist Reduces Suicide Risk

·        Another LEAN Success Story

·        A Culture of Disrespect







WHO Safe Childbirth Checklist



Checklists are some of the most valuable tools we have available in quality improvement and patient safety. They are simple and save time in the long run and help you remember to do things you might otherwise overlook. We’ve discussed the WHO Surgical Safety Checklist and its successful implementations often (see our Patient Safety Tips of the Week for July 1, 2008 “WHO’s New Surgical Safety Checklist”, September 23, 2008 “Checklists and Wrong Site Surgery”, and January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”). There have also been modifications of the checklist for radiologic interventions (see our June 2010 What’s New in the Patient Safety World column “WHO Checklist for Radiological Interventions”), cataract surgery (see our June 8, 2010 Patient Safety Tip of the Week “Surgical Safety Checklist for Cataract Surgery”, and others.


Another one we have not yet discussed is the WHO Safe Childbirth Checklist (Spector 2012). This checklist was developed in attempt to improve global childbirth practices. It is a simple 29-item checklist that applies (mostly) evidence-based recommendations at key times during the childbirth process. Spector et al. implemented a pilot of this checklist in India. They demonstrated an improvement in compliance with practices on the checklist from 10/29 before to 25/29 after implementation. This pilot did show a trend toward reduction in stillbirths but was not powered to assess fetal and maternal outcomes.


Implementation was very low-cost and use of the checklist was readily accepted by medical personnel. The authors attributed success to 3 factors: (1) reinforcing the core set of practices by use of the checklist (2) a reminder to complete those practices at crucial times and (3) as a tool that highlighted gaps in existing practices.


Importantly, they point out that a checklist alone is not sufficient. The program provided education about best practices, identified existing gaps in care, empowered members of the local healthcare team, did focused training, discussed potential barriers, and established a mechanism for monitoring and program evaluation.


Next step, however, is making sure that implementation of the checklist translates into hard outcomes (saving lives, both fetal and maternal, and avoiding adverse outcomes).







Spector JM, Agrawal P, Kodkany B, et al. Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program. PLoS ONE 2012; published 16 May 2012




Table S1. Elements of the WHO Safe Childbirth Checklist.






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Progress on Swallowing Testing in Stroke



Aspiration pneumonia is one of the biggest risks in patients with stroke. Our June 26, 2007 Patient Safety Tip of the Week “Pneumonia in the Stroke Patient“ focused on the evaluation of stroke patients for dysphagia prior to feeding them. 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 such as pneumonia. The incidence of pneumonia in the acute stroke population is typically in the 12-13% range with incremental costs of about $15,000 cost per case and pneumonia increases the risk of dying within 30 days threefold.


Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half  (Hinchey 2005) and there are reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols (Hinchey 2006, Book 2006). Our June 15, 2010 Patient Safety Tip of the Week “Dysphagia in the Stroke Patient: the Scottish Guideline” discussed the excellent Scottish Intercollegiate Guidelines Network guideline “Management of patients with stroke: identification and management of dysphagia. A national clinical guideline”.


Our February 2012 What’s New in the Patient Safety World column “Swallowing Evaluation in Stroke” noted that the ideal screening tool remains elusive. A 2011 study (Schepp 2011) identified 35 dysphagia screening tools in the literature but found only four that met the basic criteria of reliability, validity and feasibility. Each of the 4 protocols had sensitivities of at least 87% and negative predictive values of at least 91% (compared to the gold standard of a formal swallowing evaluation/videofluoroscopy).


One of the tests mentioned in the Schepp article (Schepp 2011) was the Modified Mann Assessment of Swallowing Ability (MMASA). However, they spent little time discussing this test because it had been validated only in small sample sizes. Now researchers from the Frenchay Hospital in the UK (Keller 2012) have reported a 75% reduction in pneumonia in stroke patients after implementation of a screening program in stroke patients using the Modified Mann Assessment of Swallowing Ability (MMASA). This tool can be administered at the bedside in 5 minutes, compared to almost one hour for the full Mann Assessment of Swallowing Ability. Previous studies have documented sensitivities, specificities, and positive and negative predictive values similar to the other tests mentioned in the Schepp article (Schepp 2011) mentioned in our previous column.


Prior to implementation of the MMASA screening the pneumonia rate in stroke patients was 12%. After implementation it dropped to 3%, while corresponding national rates in the UK were still in the 13% range.


So some progress is being made in identifying screening tools for dysphagia in stroke patients. More importantly, the studies are beginning to show that use of such tools has an impact on important clinical outcomes.






Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal Dysphagia Screening Protocols Prevent Pneumonia. Stroke 2005; 36: 1972-1976 http://stroke.ahajournals.org/cgi/content/abstract/36/9/1972?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hinchey&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT



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




Book DS, Dostai J, Sama D. Compliance with Written Care Protocols Predicts Success in Achieving JCAHO Stroke Performance Measures: P469. Stroke 2006; 37: 739




Schepp SK, Tirschwell DL, Miller RM, Longstreth WT. Swallowing Screens After Acute Stroke: A Systematic Review. Stroke 2011; published online before print December 8 2011




Keller DM. New Swallowing Test Reduces Pneumonia in Stroke Patients. Medscape Medical News May 30, 2012 referencing Baldwin N et al. Abstract #24 at the XXI European Stroke Conference. Presented May 22, 2012








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VA Checklist Reduces Suicide Risk



We’ve discussed the risk of inpatient suicide in multiple columns, both on mental health units and on med/surg units or ICU’s (see list of columns at the end of today’s column).


And we’ve discussed some of the tools available to help identify risk factors for inpatient suicide that might be mitigated or avoided. In our January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides” we noted that the VA had developed a mental health environment-of-care checklist (MHEOCC). That checklist is available online on the VA Patient safety website. In our February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides” we noted an article on use of that checklist (Mills 2010). They implemented the checklist at 113 VA facilities and identified over 7000 potential hazards. A real value of the checklist is that it not only itemizes hazards but it is actually weighted by potential severity of the risk of each hazard (on a scale of 1 to 5). The commonest hazards they identified were anchor points that could be used for hanging. The second most common hazards were materials that could be used as a weapon against staff or other patients. Third most common were security issues that raised the risk for elopement. They also looked at the location of hazards and noted that bathrooms and bedrooms were a frequent site for hazards. Those two rooms obviously are potentially at greater risk for suicide because of patient isolation. Their discussion of the elopement risk is also quite good. They note certain areas (eg. physical therapy rooms, art rooms, group rooms, utility rooms, etc.) where it is important to identify that patients will not be left unsupervised and they discuss safeguards such as self-closing and locking doors. Though they discuss the use of video camera monitoring, they point out that it is unreasonable to expect staff to reliably monitor video screens for long periods of time. They also point out that, though they found materials for suffocation or poisoning less often, the high potential for lethality of those materials merits special attention. This would include items like plastic liners in trash cans and cleaning products. Those are especially important to look for on units other than psychiatric units. Overall, this is a very good checklist for conducting environmental rounds with a purpose of reducing potential risk for suicides.


Now a new study demonstrates that use of the MHEOCC significantly reduced the risk of inpatient suicide (Watts 2012). They compared suicide rates in VA hospitals before implementation of the MHEOCC with those after implementation and found a substantial reduction in the rate (from 2.64 suicides per 100,000 inpatient mental health admissions to 0.87 per 100,000). This translated to a 62% reduction in suicide rates at VA hospitals, compared to an estimated 21% reduction in non-VA hospitals over the same timeframe. The most frequently identified hazards were anchor points in bathrooms or closets. They suggest use of shower heads that do not provide anchor points and use of breakaway clothing hooks. They also note that the 3 suicides that occurred in the VA system after implementation the hazard could have been identified and abated through use of the MHEOCC.


So the MHEOCC is a very good tool for identifying and abating environmental factors that might facilitate inpatient suicide. Don’t forget that patients admitted to mental health units may also go to other sites in the hospital (eg. radiology). So make sure that you also assess the environmental risk in places like bathrooms in radiology.



Some of our prior columns on preventing hospital suicides:


·        January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides

·        February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides

·        March 16, 2010 Patient Safety Tip of the Week A Patient Safety Scavenger Hunt

·        December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units

·        September 27, 2011 Patient Safety Tip of the Week “The Canadian Suicide Risk Assessment Guide

·        December 2011 What’s New in the Patient Safety World column “Columbia Suicide Severity Rating Scale







Mental Health Environment of Care Checklist




Mills PD, Watts BV, Miller S, Kemp J, Knox K. DeRosier JM, Bagian JP.

A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals
Joint Commission Journal on Quality and Patient Safety. Volume 36, Number 2, February 2010 pp. 87-93(7)



Watts BV, Young-Xu Y, Mills PD, et al. Examination of the Effectiveness of the Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units. Arch Gen Psychiatry. 2012; 69(6): 588-592






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Another LEAN Success Story




Our Patient Safety Tips of the Week October 11, 2011 “LEAN in the Lab” and May 1, 2012 “More LEAN Successes” highlighted some of the successful applications of LEAN thinking in improving workflows in the lab, emergency department, OR, etc. LEAN, borrowed largely from Taiichi Ohno and Kiichiro Toyoda and the Toyota Production System, is both a performance improvement tool and a unique culture.


Now another LEAN success story demonstrates a significant improvement in OR turnover time (TOT) and turnaround time (TAT) that provides a significant opportunity for additional revenue and led to improvement in OR morale in an academic hospital (Collar 2012). They assembled a multidisciplinary team made up of scrub nurses, circulating nurses, anesthesiologists, surgical technicians, surgeons, scheduling personnel and administrators. After flowcharting they identified “muda” (waste) and steps that added no value from the perspective of the customer.


Examples they found of waste included delays in arrival of supervising anesthesiologists, delays in preparing instrumentation for subsequent cases, incomplete paperwork (eg. H&P’s, consents, etc.), and poor synchronization between arrival of the patient and the rest of the surgical team in the OR. Some of their solutions were simple, such as implementation of automated paging systems to summon the relevant parties at the right times. Another included having faculty complete 100% of the documentation at the last clinic visit prior to scheduled surgery and making that document readily identifiable by perioperative personnel.


The project resulted in a mean reduction in TOT of 9 minutes and about a 20 minute reduction in TAT. In addition, the frequency of cases finishing after 5 PM was cut in half.  They did not measure the savings in overtime compensation but the opportunity for new revenue created was estimated to be $330,000 annually for a single OR. A survey of staff revealed improvement in morale and surgical residents noted no change in their educational experience.


The article also describes a tool we have not previously commented on – the swim lane diagram (Green 2010). Such a diagram plots workflows as they may typically occur in silos and gives you a good picture of what workflows are often going on in parallel. Arrows between lanes can show where the processes in one “lane” can impact the flow in another “lane”. It is thus helpful in showing you how such workflows can give rise to bottlenecks in other “swim lanes”.


See our previous columns on LEAN for good references and resources to get you started learning about how LEAN can help transform your work.






Collar RM, Shuman AD, Feiner S, et al. Lean Management in Academic Surgery. J Am Coll Surg 2012; 214(6): 928-936




Green B. How to Create a Swim Lane Diagram. The Lean Logistics Blog.

September 1, 2010






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A Culture of Disrespect



Every year during our “Incoming Residents’ Week” we do an introduction to patient safety session for several hundred residents. As you’ve heard us in the past, we like “stories, not statistics” so we usually begin with a video that is hard to forget. For several years we have begun with Sue Sheridan’s heart-wrenching testimonial and plea from the TeamSTEPPS™ program. That’s a hard one to beat. But this year we are using a new video “Lucian Leape on Key Lessons in Patient Safety” in which he highlights what he considers to be the number one problem in patient safety today: we have a culture of disrespect.


Fortuitously, a recent ISMP Newsletter (ISMP 2012) highlights and summarizes Dr. Leape’s recent 2-part series on the culture of disrespect (Leape 2012a, Leape 2012b). Read the ISMP summary if you’re short on time but at some point read the full articles by Leape et al. He really hits the nail on the head! On many occasions you’ve heard us say that the biggest reason we have failed to move the bar in patient safety is that we have failed to change the culture to one of safety. But Leape’s argument is that our pervasive culture of disrespect is what is blocking our ability to move to a culture of safety.


He and his colleagues describe disrespectful behavior in 6 categories. While we all easily recognize the first category – the disruptive physician – such account for a relatively small proportion of the problem. Moreover, the disruptive physician is easiest to recognize and probably easiest to take action on. Since the Joint Commission’s Sentinel Event Alert #40 “Behaviors That Undermine a Culture of Safety”, issued in 2008, most hospitals have taken steps to identify egregious behaviors and deal with them appropriately.


But Leape’s main point is that the behaviors in the other categories are the more subtle parts of the continuum of disrespect and collectively the far bigger problem. Most of the culture of disrespect is rooted more deeply in the highly hierarchical environment in medicine where the physician has been traditionally accorded a stature at a different level than everyone else. Leape notes that remains a huge barrier in a time when we have to rely on growing multidisciplinary teams to manage increasingly complex medical conditons.


Importantly, while some aspects of disrespect are due to characteristics of individuals, Leape emphasizes that disrespectful behavior is also learned, tolerated and reinforced by the hierarchical hospital culture.


The second category in part 1 of the Leape papers (Leape 2012a) is humiliating or demeaning treatment of nurses, residents and students. (This is also one of situations where people begin to “learn” disrespectful behaviors and perpetuate the problem.) A third category is passive-aggressive behavior, characterized by negative attitudes, criticizing authority, blaming others, etc. The fourth category, passive disprespect, differs from passive-aggressive behavior in that the latter is often done with with anger and intent to cause psychological harm whereas passive disrespect is not malevolent or rooted in anger. Passive disrespect is much more common. It includes things like chronically being late for meetings, responding slowly to calls, not dictating charts in a timely fashion, and generally being poor team players. Resistance to good practices like hand hygiene, timeouts and use of checklists are common examples. The fifth category is dismissive treatment of patients. They include behavior like interrupting the patient while the patient is trying to explain symptoms, talking “about” the patient on rounds rather than “to” the patient, etc. The last category, systemic disrespect, includes all the system nuances that are disrespectful of patients, physicians, nurses, and all other personnel. Making patients “wait” has become an ingrained fact of life. Productivity and time pressures abound for providers of all disciplines. And minor forms are common: failure to address patients or staff appropriately, lack of “please” and “thank you”, etc. Leape et al. go on to describe the consequences of these behaviors and the many endogenous and exogenous factors involved in producing disrespectful behaviors.


In part 2 (Leape 2012b) the authors discuss what we must do to create a culture of respect. Modeling respectful conduct and leadership are critical and this must be begun in medical school or other professional schools (another of our frequent themes: we preach “teams” yet all of our education is done in silos). In addition, they recommend that part of the evaluation process for all staff (including physicians) should include an assessment of respectful behavior (perhaps in a “360 degree” review where personnel at all levels have input into the assessment). Adopting a code of conduct is another first step. But the most important piece is responding appropriately and in a timely fashion when disrespectful behavior occurs. Developing a learning environment (eg. where everyone has equal input into root cause analyses, etc.) is another key to creating a culture of respect.


Interestingly, another new article from the hospitalist literature (Reddy 2012) demonstrates how often “unprofessional” behaviors occur amongst hospitalists. Many of these behaviors noted were really expressions of disrespect for either colleagues or patients. They include things like: making fun of other physicians, having personal conversations in patient corridors, texting during conferences, “celebrating” blocked admissions, signing out work early, doing handoffs over the phone when a face-to-face handoff could have been done, etc.


Our January 2011 What’s New in the Patient Safety World column “No Improvement in Patient Safety: Why Not?” and our March 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality” also discuss failure to change the culture as barriers to patient safety and good healthcare. Turning a blind eye or deaf ear to such problems just continues to make the working environment worse for all parties involved. We’ve seen numerous occasions where staff had previously stepped forward to report such behaviors, only to be ignored or, worse yet, suffer retribution for their actions. So the organization as a whole needs to ensure a supportive environment is present so that staff do not feel uncomfortable in confronting such individuals or in addressing such threats to patient safety. You can have all the policies and procedures in the world but if your culture is not conducive to eliminating these hazards we will never move patient safety to that next level.


You’ve often heard the phrase “culture trumps ________” (fill in the blank with words like policy, procedure, strategy, tactics, vision, etc). In fact, “Culture trumps…Everything!” So until we can get at that true root cause – the culture of disrespect – all the great patient safety interventions developed over the years will continue to have a limited impact.



On second thought, don’t just read the short version of the Leape papers and don’t just watch the video. Failing to take the time to really understand the systemic nature of the problem would be an act of disrespect itself! Read the full versions along with the summary and the video. And do it over and over. We’ve got to get this one right.






"Lucian Leape on Key Lessons in Patient Safety"



ISMP. Dr. Leape and colleagues present a compelling call to action to establish a culture of respect. ISMP Medication Safety Alert! Acute Care Edition. June 14, 2012




Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. [Epub ahead of print, May 22, 2012] 2012; 87: 1-8. http://journals.lww.com/academicmedicine/Abstract/publishahead/PerspectiveACultureofRespect,Part1The.99620.aspx



Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. [Epub ahead of print, May 22, 2012] Acad Med. 2012; 87: 1-6. http://journals.lww.com/academicmedicine/Abstract/publishahead/PerspectiveACultureofRespect,Part2.99622.aspx



The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. July 9, 2008




Reddy ST, Iwaz  JA, Didwania AK, et al. Participation in unprofessional behaviors among hospitalists: A multicenter study. Journal of Hospital Medicine 2012; Article first published online: 16 MAY 2012 | DOI: 10.1002/jhm.1946





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Print “July 2012 What's New in the Patient Safety World (full column)

Print “July 2012 WHO Safe Childbirth Checklist

Print “July 2012 Progress on Swallowing Testing in Stroke

Print “July 2012 VA Checklist Reduces Suicide Risk

Print “July 2012 Another LEAN Success Story

Print “July 2012 A Culture of Disrespect













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