Regular readers of our columns recognize that when we
identify occurrence of a “workaround”, which is often detrimental to patient
safety, we always need to investigate and identify the reason(s) why that
healthcare worker had to do a workaround.
Last month, ISMP had a great column (ISMP
2016) on the need to turn “first-order thinking” (i.e. the workaround) into
second-order thinking where the organization learns and institutes long-term
solutions rather than just tolerating short-term fixes that will not prevent
recurrences.
The ISMP column notes that we value ingenuity and creativity
in healthcare. We have all seen cases where a physician or nurse has
encountered an obstacle and found an immediate solution to save a patient’s
life or otherwise prevent harm. The problem, of course, is that individuals who
use the creativity to develop a workaround or quick fix to a problem do not
often enough bring the issues to the greater attention of the organization. As
a result, there is no systemic learning and the same set of circumstances that
led to the workaround are likely to recur. The next time they recur there may
not be as creative a healthcare worker to intervene.
We’ve demonstrated how workarounds may adversely impact
patient safety in our Patient Safety Tips of the Week for June 17, 2008 “Technology
Workarounds Defeat Safety Intent”, September 15, 2009 “ETTO’s:
Efficiency-Thoroughness Trade-Offs”, and April 5, 2016 “Workarounds
Overriding Safety” and
several other columns listed below.
One question we always ask healthcare workers when we are
doing Patient Safety Walkrounds
is “Can you tell us one workaround that you have used recently?” (see our October 7, 2014 Patient Safety Tip of the Week “Our
Take on Patient Safety Walk Rounds”). We have emphasized that when you
identify issues on Patient Safety Walkrounds you need
to follow them to closure in a timely fashion and communicate back to the front
line staff that you have developed and implemented solutions. That is a point
also emphasized in the ISMP column.
Another good venue in which to identify workarounds are your
post-op debriefings (see our
multiple previous columns on debriefings listed below).
Some workarounds are effective, others are maladaptive.
Either way, they serve to identify a system vulnerability that needs to be
fixed. So when you identify a workaround is occurring you need to assess the
root cause(s) of the problem and come up with solutions. The solution might, in
fact, be the one the creative healthcare worker has used. So you need to
consider that solution and others. The most important point in the ISMP column
is that we need to create cultures that encourage healthcare workers to come
forward whenever they have had to create a workaround. If the problems leading
to use of that workaround are not brought to the attention of others, those
problems will ultimately impact care of other patients.
Some of our prior columns
related to workarounds:
September 4, 2007 “Workarounds
as a Safety Issue”
May 2008 “UK
NPSA Alert on Heparin Flushes”
June 17, 2008 “Technology
Workarounds Defeat Safety Intent”
September 15, 2009 “ETTO’s:
Efficiency-Thoroughness Trade-Offs”
August 24, 2010 “The
BP Oil Spill - Analogies in Healthcare”
March 6, 2012 “Lab
Error”
July 2, 2013 “Issues
in Alarm Management”
April 8, 2014 “FMEA
to Avoid Breastmilk Mixups”
October 7, 2014 “Our
Take on Patient Safety Walk Rounds”
April 5, 2016 “Workarounds
Overriding Safety” among
other columns.
See our prior columns on huddles, briefings,
and debriefings:
References:
ISMP (Institute for Safe Medication Practices). Reporting
and second-order problem solving can turn short-term fixes into long-term
remedies. ISMP Medication Safety Alert! Acute Care Edition. 2016; May 19, 2016
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1139
Print “June
2016 ISMP Article on Workarounds”
Our numerous columns on disclosure and apology after medical
error (listed below) have stressed that such are not only the right things to
do but in the long run help patients and families reach closure and help
prevent other similar errors and adverse outcomes. In addition, that approach
is now widely accepted as reducing litigation and malpractice settlements.
But the healthcare professions and organizations have
historically done a poor job in preparing individuals in providing disclosure
and apology. A new toolkit provided by AHRQ, the CANDOR toolkit, provides
excellent resources for organizations in this process (AHRQ
2016). CANDOR stands for Communication
and Optimal Resolution. The toolkit comes with 8 modules and an implementation
guide. The modules come with PowerPoint slides and videos that illustrate key
principles and speaker notes to guide the discussions.
The presentations
start with identification of a CANDOR event and how to activate your CANDOR
Response Team. Ideally, activation of the CANDOR Response Team should begin
within 30 minutes after a CANDOR event has been identified. In addition to
initiating the fact-finding investigation of the event, a CANDOR Communication
Lead should be identified and immediate emotional support to the patient,
family, and caregiver should be provided, the latter by activating the Care for
Caregiver program. The CANDOR Response Team and/or CANDOR Communication Lead
are responsible for the initial communication with the patient and/or
family. The CANDOR Communication Lead coordinates all communications, and
ensures that all caregivers are consistent in their communication, i.e., that
they stay "on message." Following the initial disclosure
conversation, the CANDOR Response Team ensures that a trained communicator
establishes ongoing regular communication with the patient and/or family.
As we’ve so often
pointed out in the past, we also need to remember that all these unfortunate
events also have “second victims”, that is the caregivers involved in the
incidents. One of the other key functions of the CANDOR Response Team is assessing
the needs of caregivers involved in the harm event and providing initial
emotional support and activating the programs your organization hopefully have
implemented for providing ongoing support for the caregivers. Details and
resources for dealing with the caregivers are provided in Module 6.
Modules 2 and 3 deal
with developing the culture your organization needs and preparing your
organization for implementation of the CANDOR program.
The first module
also describes the Event Investigation and Analysis and timeframes for its
optimal initiation and completion, which is further described in detail in
Module 4. This is basically the root cause analysis (RCA) plus other
considerations and has a checklist to help guide the team(s). Throughout the
process the importance of maintaining a “Just Culture” with shared accountability
is stressed.
That fourth module
also notes it is important to inform the patient, family, and the involved
caregivers of the investigation and analysis results. It provides resources to
help your organization engage patients and families. It also discusses how to
communicate with and involve your organization’s liability carrier. One of the
resources is a link to discussions of the University of Michigan's early
disclosure and offer program (see our September 2010 What's New in the Patient
Safety World column “Followup
to Our Disclosure and Apology Tip of the Week”).
Module 5 discusses
the response and disclosure and provides some excellent resources and
recommendations, such as how to deal with challenging communications. It
provides checklists, case scenarios, and videos of both appropriate and
inappropriate disclosures to patients.
Module 7 deals with
resolution. Resolution in the CANDOR process involves actions associated with
addressing the patient, family, and staff expectations. The main objective of
resolution in the CANDOR process is to meet the needs and expectations of the
patient. It stresses that failure to do this can lead to a loss of trust from
the patient. This component of the overall process might lead to a financial
settlement, but notes that such settlements might not always lead to resolution
of all issues related to the adverse event. Financial recompense is not always
the most important need of the patient and/or family. They often want to know
that their unfortunate event may lead to implementation of processes that will
prevent others from suffering the same consequences. It stresses the importance
of the organization taking responsibility and showing legitimate remorse. It
also has excellent resources regarding the skills required in properly
communicating with multiple parties throughout this phase.
The final module
deals with organizational learning and how to ensure sustainability of the
CANDOR program and, more importantly, the culture needed to ensure its
sustainability.
Overall, the CANDOR
toolkit is an outstanding resource that every healthcare organization must take
advantage of. Many organizations have had to stumble through handling adverse
events and had to learn the hard way. The CANDOR toolkit can help organizations
take a very proactive approach to establishing programs that are the right way
to do things.
Some of our prior columns
on Disclosure & Apology:
July 24, 2007 “Serious
Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple
Patients”
June 22, 2010 “Disclosure
and Apology: How to Do It”
September 2010 “Followup
to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI:
Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error
Disclosure by Surgeons”
June 2012 “Oregon
Adverse Event Disclosure Guide”
December 17, 2013 “The
Second Victim”
Other very valuable
resources on disclosure and apology:
References:
AHRQ (Agency for Healthcare Research and Quality).
Communication and Optimal Resolution (CANDOR) Toolkit. AHRQ 2016; Rockville, MD
http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html
Print “June
2016 Disclosure and Apology: The CANDOR Toolkit”
The “weekend effect”
(sometimes also known as the “after hours effect” since many of the same
results apply to patients admitted at night as well as on weekends) in which
increases in mortality, complications or adverse events are seen for patients
admitted on weekends has been demonstrated for a wide range of both surgical
and medical conditions. Our numerous columns on the “weekend effect” have
stressed that there are likely both patient-related and system-related factors
underlying the phenomenon (see, for example, our November 2013 What's New in the Patient Safety World column “The
Weekend Effect: Not One Simple Answer”).
Several recent
articles have challenged the concept of the “weekend effect” and pointed out
deficiencies in case identification methodologies that may give rise to
inaccurate conclusions.
Stroke is one of the
many conditions previously identified as prone to the weekend effect. One new
analysis from the UK (Li 2016),
however, looks at how use of administrative coding to identify stroke cases may
erroneously lead to this conclusion. The authors looked at stroke cases from
the Oxford Vascular Study and found that many patients admitted with a stroke
diagnosis may not, in fact, have had a new stroke. Rather many had a
previous stroke and were admitted for other reason yet administrative coding
made them appear to have had new strokes. Such patients obviously have a lower
likelihood of mortality during that admission and they are disproportionately
admitted on weekdays (often for procedures). Thus, it is not surprising that
patients admitted on weekends (who have new strokes) would appear to have
higher mortality rates. When the authors looked just at those patients with
acute (new) strokes they found no imbalance in baseline stroke severity for
weekends vs. weekdays and no difference in the 30-day mortality rates.
A second UK study on
stroke (Bray
2016) focused on the impact of not only day of the week but also time of
day of admission. They analyzed data
from the Sentinel Stroke National Audit Programme
with over 74,000 stroke patients. They found variation from day to day and time
of day for several measures of stroke care measures. Overall, they found no
difference in 30 day survival between weekends and weekdays but patients
admitted overnight on weekdays had lower odds of survival.
Another very interesting study looked at patients presenting
to emergency rooms (Meacock
2016). They postulated that restricted
service availability at weekends on the outpatient side may lead to selection
of patients with greater average severity of illness for admission. They found
that similar numbers of patients attended emergency rooms on weekends and
weekdays and there were similar numbers of deaths amongst patients attending
emergency rooms on weekend days compared with weekdays. Attending emergency
rooms at the weekend overall was not associated with a significantly higher
probability of death. Higher mortality rates at weekends are found only amongst
the subset of patients who are admitted. They conclude that reduced
availability of primary care services and the higher admission threshold at
weekends mean fewer and sicker patients are admitted at weekends than during
the week.
And a fourth study,
again from the UK, challenged previous studies that had suggested lack
of availability of specialists on weekends was responsible for higher mortality
rates for patients admitted on weekends. Aldridge and colleagues (Aldridge
2016) found that substantially
fewer specialists were present providing care to emergency admissions on Sunday
than on Wednesday (11% vs. 42%) but specialists present on Sunday spent 40%
more time caring for emergency patients than did those present on Wednesday. Moreover, the median specialist intensity on
Sunday was only 48% of that on Wednesday. Thus, their analysis did not detect a
correlation between weekend staffing of hospital specialists and mortality risk
for emergency admissions.
Our own opinion is
that the “weekend effect” and “after-hours effect” are real phenomena but that
the causes are multifactorial, including both patient-based and system-based
contributing factors. We suspect that, yes, patients admitted at these times
are likely sicker and have a higher severity of illness and therefore are
likely to have a higher mortality rate. However, as we’ve pointed out over and
over, hospitals do not provide the same levels of service 24 hours a day, seven
days a week. Staffing patterns, in terms of volume and even more so in
terms of experience, are the most obvious difference but there are many others
as well. Many diagnostic tests are not as readily available during these times.
On-site physician availability may be different and cross-coverage by
physicians who lack detailed knowledge about individual patients is common. You
also see more verbal orders, which of course are error-prone, at night and on
weekends. But the most
significant difference is nurse workload on weekends. We’ve described the
tremendous increase in nurse responsibilities on weekends due to lack of other
staff (no clerical staff, delayed imaging, physicians not on site) that add
additional responsibilities to their jobs. Our December 15, 2009 Patient Safety
Tip of the Week “The
Weekend Effect” discussed how adding non-clinical administrative tasks to
already overburdened nursing staff on weekends may be detrimental to patient
care. Just do rounds on one of your med/surg floors
or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing
interruptions in some attention-critical nursing activities. Calls from
radiology and the lab that might go directly to physicians now often go first
to the nurse on the floor, who then has to try to track down the physician.
They end up filing lab and radiology reports or faxing medication orders down
to pharmacy, activities often done by clerical staff during daytime hours. Even
in those facilities that have CPOE, nurses off-hours often end up entering
those orders into the computer because the physicians are off-site and are phoning
in verbal orders and this may soon get worse as The Joint Commission is now
allowing orders to be texted in (see our May 24, 2016 Patient Safety Tip of the
Week “Texting
Orders – Is It Really Safe?”).
You’ll also see nurses giving directions to the increased numbers of visitors
typically seen on weekends. They may even end up doing some housekeeping chores
and delivering food trays. All of these interruptions and distractions obviously
interfere with nurses’ ability to attend to their clinically important tasks
(see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions,
Distractions, Inattention…Oops!” and May 4, 2010 “More
on the Impact of Interruptions”). That is why we think that simply
addressing nurse:patient
staffing ratios without addressing nurse workload issues may be short-sighted.
So while the recent
articles may dilute the weekend effect for some conditions, all you have to do
is spend some time in your hospital on weekends and you’ll readily see that
things are different on weekends.
Some of our previous
columns on the “weekend effect”:
·
February 26, 2008 “Nightmares….The
Hospital at Night”
·
December 15, 2009 “The
Weekend Effect”
·
July 20, 2010 “More
on the Weekend Effect/After-Hours Effect”
·
October 2008 “Hospital
at Night Project”
·
September 2009 “After-Hours
Surgery – Is There a Downside?”
·
December
21, 2010 “More
Bad News About Off-Hours Care”
·
June
2011 “Another
Study on Dangers of Weekend Admissions”
·
September
2011 “Add
COPD to Perilous Weekends”
·
August
2012 “More
on the Weekend Effect”
·
June
2013 “Oh
No! Not Fridays Too!”
·
November
2013 “The
Weekend Effect: Not One Simple Answer”
·
August
2014 “The
Weekend Effect in Pediatric Surgery”
·
October
2014 “What
Time of Day Do You Want Your Surgery?”
·
December
2014 “Another
Procedure to Avoid Late in the Day or on Weekends”
·
January
2015 “Emergency
Surgery Also Very Costly”
·
May 2015
“HAC’s
and the Weekend Effect”
·
August
2015 “More
Stats on the Weekend Effect”
·
September
2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
·
February
23, 2016 “Weekend
Effect Solutions?”
References:
Li L, Rothwell PM on behalf of the Oxford Vascular Study.
Biases in detection of apparent “weekend effect” on outcome with administrative
coding data: population based study of stroke. BMJ 2016; 353: i2648
http://www.bmj.com/content/bmj/353/bmj.i2648.full.pdf
Bray BD, Cloud GC, James MA, et al. Weekly variation in
health-care quality by day and time of admission: a nationwide, registry-based,
prospective cohort study of acute stroke care. Lancet 2016; published online first
May 10, 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930443-3/abstract
Meacock R, Anselmi
L, Kristensen SR, et al. Higher mortality rates
amongst emergency patients admitted to hospital at weekends reflect a lower
probability of admission. J Health Serv Res Policy 2016; Published online before print
May 6, 2016
http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.abstract
Aldridge C, Bion J, Boyal A, et al. Weekend specialist intensity and admission
mortality in acute hospital trusts in England: a cross-sectional study. Lancet
2016; published online first May 10, 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930442-1/abstract
Print “June
2016 Weekend Effect Challenged”
One of the reasons that rapid response teams have been less
successful than we all once anticipated is due to weakness on the afferent limb
of the rapid response system – i.e. that we don’t identify clinically
deteriorating patients soon enough to make a difference. Therefore, multiple
attempts have been made to develop scoring systems like MEWS (the modified Early
Warning Score) that will help in that earlier identification. Many such systems
have been automated, using data readily available from electronic medical
records and computerized monitoring devices.
One recent study used real-time automated continuous
sampling of electronic medical record data to enable early identification of
patients at risk for death (Khurana
2016). An alert would trigger when at least 2 of 4 systemic
inflammatory response syndrome (SIRS) criteria plus at least one of 14 acute
organ dysfunction parameters was detected. 5.2% of patients for whom the alert
triggered died compared to only 0.2% of those without the alert. Those for whom
alerts triggered also had more hospital days and ventilator days. In the
validation phase, the sensitivity, specificity, and positive and negative
likelihood ratios for predicting mortality were quite good.
It’s, of course, interesting in that we just recently
applauded the proposed removal of the SIRS criteria from the definition of
sepsis (see our March 2016 What's New in the Patient Safety World column “Finally…A
More Rationale Definition for Sepsis”). However, the current study would certainly suggest that the SIRS criteria
may still be valuable when part of a broader score in predicting mortality in
hospitalized patients.
Some of our other
columns on MEWS or recognition of clinical deterioration:
Our other columns on
rapid response teams:
Our other columns on
sepsis:
References:
Khurana HS, Groves RH, Simons MP,
et al. Real-Time Automated Sampling of Electronic Medical Records Predicts
Hospital Mortality. The American Journal of Medicine 2016; published online 17
May 2016
http://www.amjmed.com/article/S0002-9343%2816%2930294-7/abstract
Print “June
2016 An EMR-Based Early Warning Score”
Print “June
2016 What's New in the Patient Safety World (full
column)”
Print “June
2016 ISMP Article on Workarounds”
Print “June
2016 Disclosure and Apology: The CANDOR Toolkit”
Print “June
2016 Weekend Effect Challenged”
Print “June
2016 An EMR-Based Early Warning Score”
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