Archive for the ‘Checklists’ Category

Wrong side wrong system?

In BEST.ARTICLE.EVER., Checklists, Force function, Human Factors on May 9, 2013 at 7:28 am

Another article about a recent wrong side surgery:

SSM Health Care acknowledged Tuesday that its neurosurgeon and medical staff recently operated on the wrong side of a St. Louis-area woman’s brain and skull.
The admission — and a lengthy public apology — followed a Post-Dispatch story in Tuesday’s paper about a lawsuit filed Friday on behalf of Regina Turner of St. Ann.
“SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room,” Chris Howard, president and chief executive of SSM Health Care-St. Louis, said in a written statement. As a result of the mistaken surgery on April 4, Turner, 53, now needs 24-hour nursing care for her basic needs and cannot speak intelligibly, said Alvin Wolff Jr., her Clayton-based attorney.
According to the lawsuit filed in circuit court in Clayton, the former paralegal “will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”

“This was a breakdown in our procedures, and it absolutely should not have happened,” Howard wrote in his statement. “We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion. We immediately began an investigation.”

Time outs and checklists have reduced the incident of wrong side surgery but not eliminated the problem. Let’s analyze this from the human factors/risk management Hierarchy of Intervention Effectiveness (see graphic below). Capture
While checklists and standard time-outs are better than education, they do not reach the level of automation or force function.

In the words of Cafazzo & St-Cyr (2012,
“Although checklist use has recently made headlines in its ability to reduce adverse events in settings such as the operating room and intensive care (Haynes et al. 2009; Pronovost 2006), it remains unclear that an intervention so fundamentally reliant on human behaviour will be sustainable in the long term without constant enforcement (Bosk et al. 2009). Are all healthcare organizations able to create a culture for the sustained use of checklists? If this solution applies only to organizations that have the leadership and resources to maintain such a culture, checklists – and other solutions reliant on human behaviour – cannot be considered a systemic solution. Given how rare serious adverse events are to the total volume of healthcare encounters, a solution that applies to only a fraction of organizations cannot address this safety issue fully.”

My thoughts: why can’t we ace wrap the WRONG side…with a distinctive sterile wrap designed like yellow police tape (DO NOT CROSS!).. it can be removed once the first cut is made into the appropriate surgical site.
Simple, but it would provide some force function as the team would literally have to remove a wrapping that said “WRONG SIDE” in order to make a mistake!

Graphic: Cafazzo and St-Cyr, 2012

A leading cause of death in the US…

In Checklists, culture, Force function on February 9, 2012 at 7:28 am

from Kaiser HEalth news

“In 2010, the federal government estimated that faulty medical care contributed to the death of about 15,000 Medicare patients per month. By these meas­ures, faulty hospital care is one of the leading causes of death, behind heart disease and cancer.

Why haven’t hospitals made more progress on patient safety? The reasons are multiple and complex, but they boil down to the fact that hospitals are hierarchical organizations resistant to change, they haven’t done enough to create environments in which patient safety is a priority, and they’ve been reluctant to share patient-safety data with the public.

Even getting full compliance on basic safety standards, such as washing hands, has proved elusive because hospitals are busy, high-stress places full of distractions.

“We are humans and are destined to make mistakes,” says Nancy Foster, vice president of quality and patient-safety policy at the 5,000-member American Hospital Association. “The question in health care is: Can we design processes and have them in place so when an individual makes a natural mistake, that mistake doesn’t result in harm to patients?”

continue reading this article

Is 66 days enough?

In Checklists, Human Factors, Patient Safety, Safety climate on October 6, 2010 at 12:20 pm

One of the difficulties in infusing safety into the healthcare environment is getting safety behaviors habitually into bedside practice. The previously referenced degradation of the anesthesia safety policy published in Quality and Safety in Health Care is a perfect illustration of this dilemma. View the full text of this article The natural lifespan of a safety policy: violations and system migration in anaesthesia.

A recent experiment published in the European Journal of Social Psychology contained the results of a study focused on the length of time it took to insinuate a behavior into habit…. Read the rest of this entry »

Rapid Response, MEWS and PEWS

In Checklists, Patient Safety on September 6, 2010 at 3:40 pm

Many Rapid Response teams have been formed in hospitals as a result of the IHI’s 5 million Lives campaign. Early warning system tools are also a recommendation along these lines to help identify when activate the Rapid Response Team. One hospital in Wales has developed MEWS* (Modified Early Warning System). The MEWS consists of a scoring tool and interventions based on these scores in assessing a deteriorating adult patient. View the MEWS. The tool is compact in that the scores in the middle show zero for normal then go out to the left as 1-2-3 for parameters that are dangerously low and out to the right as 1-2-3 for parameters that are dangerously high. Interventions for scores are listed at the bottom. This is a user friendly all-in-one algorithm/flowchart template for a safety assessment tool….. Read the rest of this entry »

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