Patient Safety Tip of the Week

March 16, 2010

A Patient Safety Scavenger Hunt

Last week was Patient Safety Awareness Week and many hospitals had some great programs to not only make their staffs more aware of patient safety issues but also to make their patients and their families more aware. Many healthcare organizations held contests and gave awards to those who identified patient safety hazards or submitted some good ideas to improve patient safety.

But shouldn’t we be rewarding staff who make good patient safety suggestions any time? Why do we need a special week to do that? Every healthcare organization should have a standing program where all patient safety suggestions are evaluated and those that are implemented have awards go to the persons who suggested them. Those awards don’t have to be big monetary rewards. Often recognition in your staff or hospital newsletter or on your Patient Safety Champion of the Month poster is gratifying and helps promote creative ideas. Just as importantly, each time someone makes a suggestion you need to make sure you get back to them at some point to let them know whether you implemented their suggestion.

But you can also make patient safety fun at the same time you are identifying hazards in your organization. One example is the “Patient Safety Scavenger Hunt”. In this exercise you award points for identifying patient safety hazards or risky situations or practices. Give your staff a finite period of time (eg. 2 hours) to look for these and award points for each item identified within that time frame. Use multiple staff and you may need to pair them up for the search for some of the items (like the suicide risk ones). Here are some examples you would award points for:

Alarms disabled (or otherwise manipulated to make them less likely to alert staff to dangerous situations)
Maximum allowable points = 4
Clue: head straight to the ER, ICU’s and dialysis suite (see our February 23, 2010 Patient Safety Tip of the Week Print “Alarm Issues in the News Again”)

Suicide risks. Find a location not on a behavioral health unit where a potentially suicidal patient is likely to temporarily be located and where they might lock themselves in. Award points for how many minutes it takes for staff to get access to that site (i.e. unlock the door) and points for how many potentially lethal items are in that room (eg. loopable structures on ceilings or walls, places a patient could jump from, toxic chemicals, etc.)
Maximum allowable points = 10
Clue (for those having behavioral health units): head straight for the radiology suite and look at the bathrooms there
Clue (for those lacking behavioral health units): find a utility closet on any med/surg unit

Clue: for this exercise you’ll need 2 people, one to lock themselves in a room and the other to go look for help

Hand hygiene patrol (identify instances where a healthcare worker goes from one patient room to another without washing his/her hands)
Maximum allowable points = 6
Clue: look in almost any patient care area (but you only get ½ point for identifying each physician who fails to wash his/her hands because they are about half as likely as a nurse to wash his/her hands)

Delirium risk. Identify the number of elderly patients who are at risk for delirium who are receiving sedating medications (beware of HIPAA issues in this one but keep in mind that you can do this as long as you are performing it as a quality improvement exercise)
Maximum allowable points = 5.
Clue: You’ll easily find these patients in any ICU, post-op care area or med/surg unit.

Catheter patrol. Find instances of a catheter or other indwelling device that is no longer indicated for patient care (though you’ll probably identify urinary catheters most often, also include other devices such as central venous catheters, arterial lines, ventriculostomy tubes, etc.)
Maximum allowable points = 6
Clue: start anywhere you take care of post-op patients or any ICU (this patrol takes a little longer because you need to assess the medical indications for continuation of the device)

Dangerous abbreviations. Take any dangerous abbreviation that appears on ISMP’s list of error-prone abbreviations but does not appear on your dangerous abbreviation list and find out how often that abbreviation appears in your medical record, orders, etc.
Maximum allowable points = 10.
Clue: don’t look for them all, just look for common ones like “D/C”, “@”, “qHS”, “>”, “<”

Look alike/sound alike drugs (LASA’s). How often are drugs in a LASA pair not written in tall man lettering (either handwritten or electronically entered) or how often are vials of a drug that have a similar appearance stored in close proximity in any area (pharmacy or nursing unit or automated dispensing machine)
Maximum allowable points = 4.
Clue: We would stick to high-risk medications here (eg. insulins, narcotics, heparins)

BMV workarounds. Identify examples where the safety mechanisms in a bedside medication verification (barcoding) system are purposefully bypassed
Maximum allowable points = 3.
Clue: shadow a nurse doing medication dispensing using BMV

A sample scorecard is available below or a printable version by clicking here. The maximum score is 50.

We are willing to bet that when you first do this scavenger hunt one person/team will always hit the maximum point total. Let different staff members participate each time. You then need to keep repeating the scavenger hunt periodically until you get the point total below a certain level consistently. Once you have done that, move on to some new items and start all over again. Or you could substitute different items for the ones listed above. For example, rather than just looking for sedating agents in patients at risk for delirium, you could look at use of “potentially inappropriate medications” (from Beer’s list) in your 65-and-older population (see our January 15, 2008 Patient Safety Tip of the Week “Managing Dangerous Medications in the Elderly ” and June 2008 What’s New in the Patient Safety World “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”).

The items we have provided here are the ones we know we can identify easily in almost every hospital we visit. The value of the exercise is that, by involving multiple staff, it begins to sensitize them to omnipresent patient safety risks and helps them become more vigilant for risks in their day-to-day activities.

Patient Safety Scavenger Hunt Scorecard

Category	Item	Points	Score
Alarms disabled		6 maximum
	Alarms disabled Alarms volume turned down Alarms parameters set too wide
Suicide risks		10 maximum
	Minutes it took for staff to unlock door Each potentially lethal item (eg. loopable objects, toxic chemicals, window/roof to jump from, etc.)
Hand hygiene patrol		6 maximum
	Nurses ID’d (1 pt.) MD’s ID’d (1/2 pt.) Other HCW’s (1 pt.)
Delirium risk		5 maximum
	# at-risk patients on sedative drugs
Catheter patrol (catheters or devices not currently clinically indicated)		6 maximum
	Foleys Central lines Arterial lines Ventriculostomies Other
Dangerous abbreviations		10 maximum
	“D/C” “@” “qHS” “>” “<”
Look alike/sound alike drugs		4 maximum
	HumaLOG/HumuLIN HumaLOG/NovoLOG HumuLIN/NovoLIN NovoLIN/NovoLOG oxyCODONE/HYDROcodone oxyCODONE/oxyCONTIN oxyCONTIN/MS contin Vials: Insulin Heparin
BMV workarounds		3 maximum
	Barcode scanned on something other than patient wrist Barcode cut and pasted on computer Warning on computer screen overridden
		Total Score:

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