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What’s New in the
Patient Safety World
November 2023
·
TeamSTEPPS 3.0 is
Here!
·
Bad Practices Lead to Fatal Medication Error
·
EHR Usability and Patient Safety
·
Importance of Timeouts Outside the OR
TeamSTEPPS 3.0 is Here!
We’ve been huge fans
of the TeamSTEPPS program since its inception.
It’s the team training program
developed by the Department of Defense (DoD) in collaboration with the Agency
for Healthcare Research and Quality (AHRQ).
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.
AHRQ recently
announced the launch of TeamSTEPPS 3.0, the latest
version of this highly successful program (Umscheid
2023). Several new features
designed to keep pace with the ever-changing dynamics of healthcare delivery are
included in the updated version:
·
Increased
Patient Focus: Training
updates help increase the involvement of patients and family caregivers in care
processes and decision making, including some new engagement methods, such as patient
videos, simulation training, and a guide for patients and family caregivers.
·
Integrated
TeamSTEPPS Platform: The new TeamSTEPPS 3.0 curriculum
consolidates content from prior versions that were created for separate care
settings.
·
Modular
Course Design: TeamSTEPPS 3.0 can be taught in sessions of varying lengths
to accommodate time constraints.
·
Active
Learning Strategies: Instead
of passive lectures, the curriculum provides various teaching options
including discussions, online group exercises, and video-based simulations.
·
Addressing
Potential Team Challenges and Leveraging New Opportunities: . TeamSTEPPS 3.0
emphasizes that the healthcare workforce is becoming more diverse and
multigenerational as the technology to support healthcare delivery, such as
instant messaging and telemedicine, is rapidly changing.
The TeamSTEPPS 3.0 Curriculum Materials are organized into
modules:
·
Module 3:
Situation Monitoring
·
Implementation
of TeamSTEPPS 3.0
Yes, there are other
teamwork training and crew resource management programs out there. But the TeamSTEPPS program is time-tested and, best of all, free!
References:
Umscheid C, Haugstetter M. With TeamSTEPPS 3.0, AHRQ Refreshes a Landmark Patient Safety
Training Curriculum. AHRQ 2023; September 12, 2023
https://www.ahrq.gov/news/blog/ahrqviews/teamstepps-30.html
AHRQ. TeamSTEPPS 3.0 Curriculum Materials. AHRQ July 2023
https://www.ahrq.gov/teamstepps-program/curriculum/index.html
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3.0 is Here!”
Bad Practices Lead
to Fatal Medication Error
ISMP recently described a case where a typical cascade of
errors led to a fatal medication error (ISMP
2023). There are several valuable lessons learned from this unfortunate
case.
An ICU patient with rectal bleeding was scheduled to have a
colonoscopy the following day. A SUPREP BOWEL PREP KIT (sodium sulfate,
potassium sulfate, and magnesium sulfate) was ordered, to be administered
orally for cleansing of the colon as a preparation for the colonoscopy. Unfortunately,
instead of SUPREP, the patient was mistakenly given NATURALYTE,
which is a liquid acid concentrate for bicarbonate hemodialysis, used as a
dialysate with hemodialysis equipment after proper dilution.
A nurse went to the medication area and saw a large plastic
container of NATURALYTE. The nurse assumed this was similar
to GOLYTELY (polyethylene glycol 3350 and electrolytes for oral
solution), the widely used bowel prep, which is much more familiar than SUPREP.
The NATURALYTE did have a barcode and the nurse attempted to scan it but it did not register, likely because is not a
medication and the barcode does not contain a national drug code (NDC), so many
medication barcoding systems do not recognize its barcode.
The article speculates the nurse might have thought NaturaLyte was a generic replacement for GoLYTELY, given that many generic products have
different brand names than the original product name and the labels list many
similar ingredients, including magnesium, potassium, and sodium. Also, both are
in large plastic containers.
Because the barcode scan failed, the nurse called the pharmacy.
But rather than sending a new labeled medication (Suprep),
or physically reviewing the product that would not scan, a pharmacist sent a
patient label that contained a barcode through the tube system for the correct
medication, Suprep. The nurse scanned the patient’s
armband, scanned the label provided by pharmacy, and administered about 240 mL
of the NaturaLyte in its concentrated form. The
patient began to drink the liquid but could not tolerate it all due to the bad
taste and became nauseous. Because the patient could not drink more of the
product, a physician noted that a feeding tube would be needed to administer
the remainder of the medication. Another nurse (on the next shift) administered
the rest of the concentrated NaturaLyte liquid
through the feeding tube. That second nurse also thought that Suprep was similar to GoLYTELY and had been substituted with NaturaLyte.
The patient died the following day. Cause of death was not known in the ISMP
article.
Lessons learned:
·
Dialysis products should not be left
intermingled with medications. ISMP notes previous incidents where 23.4% sodium
chloride injection vials were left on a nursing unit. (The same applies to
anyone leaving unusual items in medication areas. The ISMP article also
mentioned a transplant team leaving a highly concentrated potassium cold
storage preparation in a medication area. And our February 7, 2012 Patient Safety Tip of the Week “Another Neuromuscular Blocking Agent Incident” mentioned a case where an anesthesiologist
left a vial of atracurium in the refrigerator of a nursery that had a
similar appearance to vaccine vials.)
·
If a barcode is scanned and fails to be
recognized, one should consider the possibility the substance scanned is not a
medication.
·
This combination was another LASA (Look-Alike,
Sound-Alike) example. While we always try to identify drug pairs with
similar names, who considers similarity of names of substances other than
drugs?
·
Barcoding workarounds keep popping up,
tarnishing what is arguably our most potent medication safety technology.
Sending a copy of a barcode through the pneumatic tube system was a glaring
violation of barcoding safety. ISMP recommends that when a barcode will not
scan, pharmacists need to visually verify that the medication matches what is
ordered for the patient. It is not safe to send a label by itself. Labels must
be considered part of the dispensing process and should only be placed on
products by pharmacy personnel.
·
When new medications are added to the
hospital formulary (or when they are introduced to areas of the hospital where
they are not normally used) there needs to be widespread inservice
education, memos, internal newsletter articles, and/or huddles. Suprep was relatively unfamiliar to the ICU staff, compared
to the more familiar GoLYTELY.
Of course, there were likely other factors contributing to
this incident. The nurse involved was covering more than the usual number of
patients that day because of a staffing shortage. ISMP also wondered whether
pharmacy staffing that day may have prevented the pharmacist from going to the
floor to visualize the product that would not scan or simply taking a new Suprep kit up to the ICU.
See some of our other
Patient Safety Tip of the Week columns dealing with barcoding:
- June 17, 2008 “Technology Workarounds
Defeat Safety Intent”
- April 5, 2016 “Workarounds Overriding
Safety”
- February 28, 2017 “The Copy and Paste ETTO”
- January 2018 “Can We Improve
Barcoding?”
- September 2020 “More on Workarounds”
- September 28, 2021 “Barcoding Better? Not
So Fast!”
- June 2022 “Where Are You
Barcoding?”
·
May 23, 2023 “Smudges as Patient Safety
Threats”
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”
June 2016 “ISMP
Article on Workarounds”
September 2020 “More
on Workarounds”
May 23, 2023 “Smudges as Patient Safety
Threats”
References:
ISMP (Institute for Safe Medication Practices). Patient
Death Tied to Lack of Proper Escalation Process for Barcode Scanning Failures.
ISMP Medication Safety Alert! Acute Care Edition 2023; 28(19): 1-3 September
21, 2023
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Medication Error”
EHR Usability and
Patient Safety
A new study has confirmed an association between poor EHR
usability and EHR safety performance. Classen et al. (Classen
2023) note that, despite the demonstrated ability of EHR’s to reduce
medication errors, commercial EHR systems have largely failed to consistently
deliver this benefit. They also note that one explanation for these results has
been poor EHR system usability, which has been shown to negatively affect the
safety of these systems, not only failing to prevent, but in several cases
leading to, medication errors. So, they decided to formally assess the
relationship between usability and an objective measure of safety. The primary outcomes were hospital
performance on the Leapfrog Health IT Safety measure (overall and 10
subcomponents) and the ARCH collaborative frontline user experience scores
(overall and 8 subcomponents). We’ve discussed the Leapfrog Health IT Safety
evaluation tool in several columns (listed below).
There were 112
hospitals and 5689 frontline user surveys included in the study. Hospitals
scored a mean of 0.673 on the Leapfrog Health IT safety measure. The mean ARCH
EHR user experience score was 3.377 (range, 1 [best] to 5 [worst]). The
adjusted β coefficient between the overall safety score and overall user
experience score was 0.011. The ARCH overall score was also significantly
associated with 10 subcategory scores of the Leapfrog Health IT safety score,
and the overall Leapfrog score was associated with the 8 subcategory scores of
the ARCH user experience score.
The authors note
that the Leapfrog EHR/CPOE safety measurements primarily focus on prescriber
medication ordering. There was a significant association between the safety of
the operational EHR and the experience that frontline clinicians have in using
it. They note this is probably related in part to the frustration that they
experience with medication ordering in poorly designed HER’s (for example, too
many clicks and too many alerts often frustrate physicians but also cause them
to ignore the alerts).
Though an
association does not prove causality, the positive association between
frontline user–rated EHR usability and EHR safety
performance in this study certainly identifies a need to improve EHR usability.
The authors conclude that both health systems and vendors need to consider
usability as critical for the frontline users and also
as a critical safety issue and, as such, should work together with frontline
users and organizations to improve usability without compromising the integrity
of safety performance.
See some of our
previous columns dealing with the Leapfrog CPOE EHR evaluaton
tool:
- July 27, 2010 “EMR’s Still Have a Long
Way to Go”
- June 2012 “Leapfrog CPOE
Simulation: Improvement But Still Shortfalls”
- April 23, 2013 “Plethora of Medication
Safety Studies”
- March 2015 “CPOE Fails to Catch
Prescribing Errors”
- May 3, 2016 “Clinical Decision
Support Malfunction”
- November 22, 2016 “Leapfrog, Picklists,
and Healthcare IT Vulnerabilities”
- June 2020 “EMR
and Medication Safety: Better But Not Yet There”
References:
Classen DC, Longhurst CA, Davis T, Milstein JA, Bates DW.
Inpatient EHR User Experience and Hospital EHR Safety Performance. JAMA Netw Open 2023; 6(9): e2333152
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2809149
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Safety”
Importance of
Timeouts Outside the OR
The primary purpose of the surgical timeout is to ensure the
correct patient, correct procedure, correct body part, and correct laterality.
While the timeout process was originally intended for surgical cases in the OR,
it’s clear that this should be performed prior to any procedure done in any
venue. That would include the radiology suite, cath
lab, bedside, emergency department, or outpatient clinic or office. A recent
AHRQ PSNet WebM&M (Bellini
2023) described a case where a failed timeout process led to a “double”
never event: wrong patient and wrong side.
A first-year orthopedic surgery resident was consulted to
aspirate fluid from the left ankle of a patient in the intensive care unit. The
resident, accompanied by a second resident, approached the wrong patient,
obtained consent from the patient’s wife via telephone, and inserted the needle
into the patient’s right ankle. At this point, a third resident entered the
room and stated that it was the incorrect patient. The procedure was
immediately terminated and patient
and family were notified of the error. There apparently were no negative
sequelae for that patient. The correct patient was 2 beds away.
The original (incorrect) patient was not competent to
provide informed consent. The patient’s wife affirmed the patient’s name, which
was incorrect, and consented to the procedure. The report does not state how
the discussion with the wife was handled but it sounds like verification of the
patient’s name may have been via a passive rather than active process.
A timeout was apparently done (with the two residents and
the bedside nurse). But it did not include verification of the patient and
procedure location. (One wonders what was actually done
during this “timeout”). The nurse questioned why an ankle aspiration procedure
was being done on a patient who had wounds on both feet and osteomyelitis in
his left foot. The resident responded that the aspiration was to collect fluid,
not to treat osteomyelitis. One of the residents stepped away to confirm the
patient’s identity in the electronic health record and returned confident that
they were working with the correct patient. The nurse’s concern was not resolved and the procedure was initiated on the wrong
patient and wrong site.
Unfortunately, we continue to see bedside procedures
performed without timeouts. Often a resident simply goes to the supply room,
grabs a procedure kit, goes to the bedside, and performs the procedure on the
patient without any assistant to help. Prior to the
patient safety “era”, we even used to pride ourselves in being able to do
things like the “one-handed lumbar puncture” without any assistance. Boy, were
we lucky we didn’t do things on the wrong patient or wrong body part!
Our June 6, 2011 Patient Safety Tip of the Week “Timeouts
Outside the OR” highlighted a study from Northwestern University (Barsuk 2011)
on re-engineering processes for compliance with Universal Protocol for bedside
procedures. They looked at lumbar punctures, thoracenteses and paracenteses
done on the medicine services at their facilities. Analyzing their processes,
they found that staff were often unaware of Universal Protocol (or perhaps
unaware that it was required not just for OR procedures, but for bedside
procedures as well) and that nurses were frequently never notified by
physicians when their patients were undergoing such procedures. In their
redesigned process the physician initiates the process by entering an order via
CPOE with an anticipated time. This order would automatically populate the
nurse’s alert list and provide the nurse with a timeout form and notice of a
procedure-specific supply kit to procure. Only the nurse has a key to those
procedure kits. This is a forcing function that forces the physician-nurse
communication to take place. The nurse brings the timeout checklist and the kit
to the bedside at the specified time and the nurse and physician go through the
timeout procedure, which gets documented in the EMR. Compliance with Universal
Protocol went from 16% before to 94% after implementation of this redesigned
process. Elegant! That is a process we have advocated ever since. We also
recommend that a copy of the timeout checklist should be attached to the front
of all procedure kits and the kit should not be opened until the items on the
checklist have been agreed upon by all.
Of course, your timeout checklist would likely contain
several other items, such as why the procedure is being done, that informed
consent has been obtained, and what you expect to do with any specimens from
the procedure.
The authors of the WebM&M case
also stress the importance of communication and TeamSTEPPS
concepts for improving teamwork. During a timeout everyone must agree on all
the items or the procedure needs to be paused for
clarification. Anyone’s concerns need to be addressed, such as the nurse
questioning the reason for the procedure and the site.
It's essential that all members of the healthcare team
understand the intent and importance of the timeout and adhere to the process
religiously.
Some of our prior columns
related to wrong-site surgery:
September 23, 2008 “Checklists
and Wrong Site Surgery”
June 5, 2007 “Patient
Safety in Ambulatory Surgery”
July 2007 “Pennsylvania
PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons
from Ophthalmology”
July 1, 2008 “WHO’s
New Surgical Safety Checklist”
January 20, 2009 “The
WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site
Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site
Neurosurgery”
January 19, 2010 “Timeouts
and Safe Surgery”
June 8, 2010 “Surgical
Safety Checklist for Cataract Surgery”
December 6, 2010 “More
Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts
Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine
Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental
Patient Safety”
May 17, 2016 “Patient
Safety Issues in Cataract Surgery”
July 19, 2016 “Infants
and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s
Electronic Procedural Timeout”
May 2017 “Another
Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy
of a Wrong Procedure”
June 2017 “Another
Way to Verify Checklist Compliance”
March 26, 2019 “Patient
Misidentification”
May 14, 2019 “Wrong-Site Surgery and
Difficult-to-Mark Sites”
May 2020 “Poor
Timeout Compliance: Ring a Bell?”
September 14, 2021 “Wrong Eye Injections”
October 5, 2021 “Wrong Side Again”
November 9, 2021 “Ensuring Safe Site Surgery”
February 15, 2022 “Wrong-Side Chest Tubes”
May 2022 “PPSA:
Updated Wrong-Site Surgery Recommendations”
June 13, 2023 “Preventing Wrong-Site
Surgery”
References:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient
and Wrong Side. AHRQ PSNet WebM&M: Case Studies
2023; September 27, 2023
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
Barsuk JH, Brake H, Caprio T, Barnard
C, Anderson DY, Williams MV. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch
Intern Med 2011; 171(10): 941-954
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/487053
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the OR”
Print “November
2023 What's New in the Patient Safety World (full column)”
Print “November 2023 TeamSTEPPS
3.0 is Here!”
Print “November 2023 EHR Usability and Patient
Safety”
Print “November 2023 Bad Practices Lead to Fatal
Medication Error”
Print “November 2023 Importance of Timeouts
Outside the OR”
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