“Lessons Learned” is a regular column in the monthly CHPSO Patient Safety News. Examples are derived directly from event reporting by hospitals, providing the opportunity to learn from each other’s experiences and demonstrating one of the benefits of sharing through a PSO.
Case:A 46-year-old substance-dependent male went to the Emergency Department for sweating, chest pain and one week of cough, and the emergency physician had a chest x-ray ordered for him. The patient was diagnosed with pneumonia and was discharged with a prescription for an antibiotic. For weeks later, the patient returned to the ED because he was coughing up blood. The clinical team completed both a tuberculosis skin test (TST) and sputum for acid-fast bacilli.
Several reports in the CHPSO database have pointed to the inaccessibility of spare surgical parts or tools while a procedure is in progress. In several cases, unique screwdrivers or drill bits have broken, or unique-size screws went missing. In at least one instance, the incision had to be temporarily closed with an implant partially secured and the patient was scheduled for re-operation to complete the procedure another day.
Staff reported problems with patient monitors, but the equipment worked properly when tested in the biomedical engineering department. Problem tracking found that patient monitors experienced intermittent malfunctions mostly on one particular side of one particular floor, located above a loading dock. Citizens’ band (CB) or other mobile radio transmissions from vehicles arriving at the loading dock were strongly suspected to have been the cause of the patient monitor interference. Truck drivers were asked to use house phones on arriving at the hospital, and the problems were resolved.
Rules for abbreviation use generally focus on medication safety—identifying visual and textual ambiguities that may confuse other medical professionals. The ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations includes items like IU that could appear like IV or 10; and DPT, which could stand for Demerol-Phenergan-Thorazine or diphtheria-pertussis-tetanus.
The following scenario is derived from incidents reported to CHPSO:
A stable, ventilator-dependent patient (KP) was placed in a room across from the nurses’ station. The nurse caring for this patient then received a post-operative patient whose condition was deteriorating. A code was called for the post-op patient and several staff in the area responded to assist. During this emergency, KP’s ventilator tubing had become disconnected and the ventilator started alarming. However, no one responded to the alarm until a custodian passing by approached the nurses’ station and notified the unit clerk that he had noticed an alarm coming from KP’s room for several minutes and wanted to make sure someone was notified. At this point, the clinical staff realized that KP was quickly deteriorating and immediately responded. Unfortunately, they could not resuscitate KP.
Diffuse responsibility is a recognized safety concern in clinical alarm management. In order to manage the large amount of noise in busy and monitored environments, clinicians often “tune out” alarms that are not related to their own patient assignment. There is an underlying assumption that someone else is responding to an alarm associated with another clinician’s patient. Personnel in the area who are not clinicians are intimidated by alarms and assume that a clinician will respond. One approach to solving this issue is to implement the “No Pass Zone.”
Although performing a root cause analysis (RCA) after an adverse event has become standard practice in many health care organizations, there is little evidence to support that this process has improved patient safety.1 Organizational culture plays a large part in the success of an RCA; there are fundamental issues in the structure of the RCA process to address as well.
In the quality and patient safety world, we have a tendency to focus on the complexity of patient care within the hospital setting. However, a classic study by Forster, et al1, reminds us that there are many concerns for the complexity of care post-discharge. Nearly 20 percent of patients experience adverse events within three weeks of discharge; about 75 percent of which are preventable. Adverse drug events are the most common post-discharge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity.
Creating a robust database has been a true challenge at CHPSO, as well as other patient safety organizations (PSO) across the nation. There appear to be some common contributing factors to this problem:
Clinical alarm safety has been highlighted by the Joint Commission in recent months as they have identified this as a National Patient Safety Goal (NPSG). CHPSO is analyzing alarm-related reports that have been submitted by our members and is seeing some patterns.
Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm system management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within different units of a single hospital.
CHPSO and Dr. Verna Gibbs, Director of NoThing Left Behind, have been leading a multi-state collaborative with patient safety leaders in Illinois, Michigan, Missouri, North Carolina, Nebraska and Tennessee to collect and analyze events related to retained surgical items, with a particular interest in small miscellaneous items (SMI) or un-retrieved device fragments (UDF). These items are often pieces or fragments that have broken off during surgery, like screws, wires, drill bits, suction tips, and tips from tunneling devices.Because they are often small in nature and can be difficult to remove, clinicians often minimize their importance as a patient safety issue. However, these items can dislodge and migrate to other areas of the body. Metal objects can become heated when a patient undergoes a MRI.
In the State of California, drivers are prohibited from talking on a hand held device or texting while driving because it is well known that these distractions can and often lead to unsafe driving. Distractions and interruptions pull your attention away from the activity that you are involved in and may lead you to miss a step or make a mistake. In the 1980s, aviation introduced the concept of a “sterile cockpit,” which refers to a distraction-free cockpit; a time when the captain and crew engage only in flight related conversation.It had become apparent that a number of accidents and near misses were related to distracting conversation among the flight deck and cabin personnel.
Patient Safety Organizations (PSO) were created by the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) to encourage health care providers to share and learn from a collective pool of data that is legally protected from discovery during litigation. Many organizations with a mature safety culture understand the value of participating in a PSO, but unfortunately some organizations are still not on board.This reluctance has been a surprise to many in the patient safety field, but there may some misunderstandings about PSOs that are preventing organizations from benefitting from participation.
Laterality errors, also known as side discrepancies, refer to instances when the incorrect side is noted in one or more sections of diagnostic reports or documentation. For example, a radiology report that notes that a lesion is on the left side of the body, when in reality it is on the right, would be considered a laterality error. Uncorrected laterality errors are most frequently associated with wrong-side surgeries, which can result in wrong limb amputation, wrong-side arthroscopy, or resection of wrong-side organ.
If you have run an Event Type summary report in our ECRI database, you have noticed that the largest category by volume is “Other” for the CHPSO aggregate. As we have been reviewing events classified as “other” we have noticed some common themes: non-team promoting behavior (physician), poor coordination of care, and delay in care related to insufficient staffing. Over the next few months, we will look closer at each of these issues.