SafetyDog

When sorry isnt the hardest word

In adverse events, human error, Human Factors, Interuptions, Multitasking on December 14, 2014 at 8:49 am

On Monday afternoon, a tragic medication error occurred at St. Charles Bend that ultimately caused the death Wednesday of a 65-year-old patient. The St. Charles family is devastated by this situation and our thoughts and prayers go out to the patient’s family along with the caregivers who were directly involved in this case during this incredibly difficult time.

“As soon as the error was recognized, we met with the patient’s family to explain what had happened and apologized for the grave mistake. We are in the process of investigating the cause of the error and are working closely with our internal team to ensure that it will not happen again. We will be reporting the event to The Joint Commission and the Oregon Patient Safety Commission in the coming days. St. Charles has never experienced a medication error of this kind in its history.

On the surface St Charles did everything right by the family in this tragic medication error. They owned the mistake, did not blame it on individual practitioners and they apologized to the family. They go on to decribe the process by which a paralytic was dispensed instead of a seizure medication. they performed a root cause analysis and came out with an action plan. They appear committed to this action plan on every level of their organization and they seem sincere in their determination to prevent this from ever happening to another patient.

Since Ms. Macpherson’s death, we have taken several immediate steps to ensure that an error of this kind will not happen again in our facilities.
Issue 1: Incorrect drug chosen and placed into IV
Our Response: We are enforcing a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions. Verification of medication can only be completed in these areas.
Issue 2: Verification of drug dispensed
Our Response: A detailed checking process has been standardized and implemented to bring heightened awareness to the pharmacy team. New alert stickers have been added to paralytic medications and we are training nursing staff to watch for these stickers.
Issue 3: Monitoring of patient after IV started
Our Response: Nursing leaders are currently evaluating patient care processes to ensure we are following best practices. On every unit, our nurses are being hyper-vigilant about how we administer any intravenous medications. We are conducting frequent check-ins with our patients and we are consulting with patient safety experts across the country to ensure we are adhering to best practices.

The words that scare me in their action plan are those like “safety zone” “heightened awareness” and “hyper-vigilant.”
While these are admirable and many errors are caught by caregivers because of these very things, this is like medicating for an illness to cover the symptoms instead of giving a patient the cure.
Instead of a safety zone, move the dangerous drugs to another area that can only be accessed and prepared into a bag of IVF with the assistance of barcode scanning.
Instead of heightened awareness and stickers, manufacturers should make special syringes and tubing for high risk medications so they cannot be given inadvertantly.
Instead of hyper vigilance, establish staffing patterns that ensure nurses can focus on one patient at a time instead of continually multitasking. Study “priority setting” and how leaders can support front line staff by spelling out how to manage busy shifts (eg. what are essential practices for safety and what are second tier priorities like patient experience. High profile initiatives can come across as if they are more important than safety).
Proactively observe the medication process and visit nursing units to get staff’s ideas on what might be the next be error. Your staff know.
The heightened awareness and hyper-vigilance are totally people based interventions. If another medication error is made, I fear the staff will be blamed for their failure to maintain these super-human standards.

Visit http://www.sorryworks.net/oregon-hospital-apologizes-for-fatal-medical-error-shares-details-cms-272 for more info about the apology

Ebola

In Patient Safety on October 12, 2014 at 9:04 am

Ebola has the potential to be a real chink in the armor for patient safety. Here are some of my thoughts

1. anyone currently thinking of becoming a doctor or nurse is totally rethinking that decision right now. I am afraid we will end up with the worst HCW shortage the US has ever seen
2. That said, hospitals better start working on having an ageless workplace so their current staff can continue working past retirement age
3. IF current PPE has major limitations, working conditions are about to deteriorate. IT is very difficult to care for a patient in full hazardous material garb
4. Current guidelines for ebola recommend limiting the number of people entering an ebola patient’s room. Where does this leave all of our double check processes?
5. Taking off PPE is very challenging. Breaching infection control protocol during this is actually easy to do. We are going to need HCW monitored during the removal process. No institution has the funds to introduce a flood of new workers into the system. If so they will likely try to do this with non-professionals who might not have the same level of understanding of infection control no matter how much training they receive.

One bright spot: current health care environments are focused on financials such as cutting workers, encouraging multitasking, prioritizing efficiency over safety..

Ebola is chance to slow things down, go back to prioritizing safety..allow time for staff to think..and support each other.. make adjustments to facilitate an ageless workplace-its good for your older employees but also for all. And many times whats safe for healthcare workers is also safe for patients and vice versa

Often times when a person gets an illness like cancer, they call it their wake up call to stop spinning and start slowing down and paying attention to life and quality. Ebola is the healthcare systems’ wake up call..

User centered design and safety

In design, Resiliency on August 30, 2014 at 6:44 pm

How much could our health care workers contribute to patient safety if we gave them some time back?

Anita Tucker’s work …highlights how the healthcare hero culture rewards front line staff for workarounds and prevents them from actually finding permanet improvement. On the spot problem solving gets more credit than providing a permanent change. Nursing in particular is encouraged to solve problems superficially to get the patients what they need rather than improve performance over time.
Instead of fixing processes and environment, we are forcing front line staff to encouter small road blocks over and over. Its like groundhog day every shift. Let’s fix these processes..no matter how small and unglorious..let’s free up our front line staff for safety efforts!

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