Boston Globe medication error story
Drug error with protocols and pump programming.
Human factors…human machine interaction…usability…they are all in this tragic story.
All health care providers need to DEMAND easy to use technology that reduces their cognitive load not adds to it.
I wrote in a previous post about a UK study describing a hesitancy of patients to call out professionals on safety concerns. Check out the website: Engaging the patient.com
Here is one of their thought provoking posts about needing to consider all the side effects of a change. The following is about asking patients to mark their own operative sites to prevent wrong side surgeries:
“Even well-intentioned suggestions can lead to unintended consequences. We can all agree that wrong-site surgeries are needless and tragic. But ensuring that this never happens is not as simple as it would seem. In the past, patient advocates suggested patients themselves write on the body part (say a knee) to be operated on. But these marks weren’t consistent. Did ‘X’ mark the spot? Or did ‘X’ mark the knee to be avoided? What if the markings were smudged? And the marker itself can increase the risk of infection”
Read more on their site!
When errors or near misses occur they may look very different on the surface. Research in human factors however has determined that there are many similar patterns in errors that involve human-system interaction.
Some of the common patterns are (Carayon, 2007):
Paul Levy had a great post on his Not Running a Hospital blog (formerly Running a Hospital) about signage. Since this is a topic in the human factors realm, I would like to share his post and relay a story from a friend.
A couple of days ago my friend visited a local Boston community hospital known for its customer service to have a simple KUB (abdominal xray). She was told to dress in a hospital gown (I will post more about hospital gowns in the future…is having patients all look alike adding or subtracting from safety????) and wait in a waiting area. After almost 60 minutes, she noticed staff hanging around the desk and talking and laughing. Drawn to attention by this, she noticed a small sign near the desk that read “if you have to wait more than 15 minutes please let us know.” She became upset at having spent an extra 45 minutes of her workday because no one had pointed out the sign or the policy. Clearly this hospital had identified some glitches in its process to post this sign. While we want to involve patients, it should not be their responsibility to monitor their wait time. Why not just scan your waiting room 4 times an hour and mark who is there on a dry erase board? Employees can have all sorts of visible reminders to do this. Also notify the patients that your goal is to see them in 15 minutes from their check in time. Most people probably never even see the sign.
With another recent case of a kidney transplant mix-up (luckily causing no harm to the patient) we really have to redefine our hospital processes. We have to involve the patients but by the time the process ends with them, we need to make sure we have made enough hard stops that an error will never reach them. Some people will report that if the patient helps to stop the error then the redundancy system works. And signs probably won’t do much good unless they are reviewed and explained. In most cases signs should be a reminder and a redundant communication, not a primary communication. An error being stopped at that level should be a VERY rare occurrence. Also to consider is a study by Davis, Sevdalis & Vincent (2011) which found many patient in the UK reluctant to engage in safety behaviors that became more challenging in nature to a doctor or a nurse.
See previous post on TEAM UP with patients from the DOD
For fans of the show American Idol, this season should prove to be a good one. Gone are the cookie cutter pretty-people contestants of past seasons. This year there is a diverse group of entrants one of whom actually played a “big bass” on the show the other night in an inspired performance. To hear a well known song, played and sung with such originality can almost move the audience and the judges to tears. It is the creativity of humans that endears us and allows us to survive as a species. Often heard advice from the judges is that while song choice is key, making it your own is what puts you ahead of the pack.
What does this have to do with patient safety?
I would like to compare a song to a patient safety practice. There are so many organizations now from which an organization can view some best practices for safety. Why do we then still have studies coming out with less than stellar improvements in the past decade of the patient safety movement? Could it be because the song choice was there but the applicable originality was not? Perhaps we need to take each standard safety process and truly make it our own…adapt it to the culture, adapt it to the patient population and the values of that population, and simplify the process considering how things flow in your organization. Really make it your own and it just might win you some safer outcomes. Just because it “worked” in one environment does not guarantee success in yours.
And just as contestants are voted on and judged, the safety practice should constantly be evaluated for how well it is working and surviving…
The Boston globe recently published sort of a lay person’s view of the issue of monitor fatigue. Some of the comments that follow by readers illustrate the classic mistake in approaching human error: to blame the human. There are a small number of posts that host some derogatory comments about nurses and their capability and commitment to patients. Over at the Human Factors Blog they have published a response to this article using, obviously a human factors lens.
Check it out here..False alarms in the hospital
To check out the Globe article click here: Part one Part two
Safetydog’s previous post on this topic with more references: Alarm fatigue
Global patient safety alerts website from our friends up north.
This site is searchable! Here is a list of results I got from searching “pediatrics”
2003-08-01
Chemotherapy Error Prompts Review of Medication Order Processing
2008-07-01
Inadvertent insertion of an Intravenous line into a premature infant’s artery results in peripheral ischemic damage to distal arm and hand
2009-03-01
Undiagnosed Community-acquired MRSA in a pre-school child
It is great that there are companies totally focused on assisting humans in preventing error. Here is an example of a sponge counting solution:
interview with CEO of Patient Safety Technologies.
TWST: How unique is the Safety-Sponge System?
Mr. Stewart: The Safety-Sponge System is a patented, proprietary product exclusive to SurgiCount Medical. It is distributed exclusively through Cardinal Health (CAH), but it is available to any hospital through their current distribution partners. The product is a very straight-forward application of automatic identification technology that addresses the underlying cause of the vast majority of retained sponges – human error.
Before and after every surgical procedure, all surgical articles used, including sponges, are counted to make sure that they are not unintentionally left inside the body. Our solution tracks sponges, the most difficult and problematic articles to account for, down to the individual level by adhering a simple, unique identifier to each one. Used in conjunction with a small handheld scanner, we call it the SurgiCounter, the system allows for more accurate counts prior to the patient being closed.
While this is great, I propose to take it even further…invent something that attaches to the sponges like a lifeline so they never get hidden in the first place (then count them using the technology as a backup).
I also propose the companies look at making syringes and other equipment with small caps and pieces more pedi friendly by attaching the caps and small pieces. This can prevent the nurse or MD from inadvertently dropping a piece, creating a choking hazard. Inventors: we need you!
click to read a great summary on patient safety science from the Josie King* website written by Peter Pronovost:
*While you are there browse the foundation’s website. Josie King was a young child who died as the result of medication errors and miscommuncations as well as ineffective teamwork systems.
On the hierarchy of safety interventions, system or product redesign falls in the level of highest effectiveness. For example, if you want to prevent nurses from infusing formula into an IV line, you redesign the formula tubing so that it cannot physically fit into IV devices.
Reorganizing a workspace may be used as a safety intervention. In the Human Factors blog, they talk about organizing by taxonomy vs taskonomy.
They use the example of making a kitchen more user friendly but this concept of taskonomy can definitely be applied to hospital areas.
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