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Accountability is not always about one personI have found during my experience as both a nurse and quality professional that frontline staff’s perception of medical errors is of a punitive nature. Even questions asked about what could potentially harm your patient today, while in your care, provoke that look of fear and sometimes even defensiveness. There truly appears to be a "wall" of some kind, a resistance to wanting to "go there." So I change the subject and might ask them to show me how medications are retrieved from the med room/dispensing station. We go through the steps and the process. I will ask questions such as: do you ever find a medication in the wrong drawer or multiple patients’ medications in the wrong drawer? The nurse appears willing to talk about the fact that pharmacy does make errors from time to time. I probe a bit and say: how do you think that might happen? Well, they could be a new employee in the pharmacy, or maybe they didn’t do a double check? So I ask: how do you as a nurse double check that you have the right medication from the drawer? (I hope the answer is not ‘Well, I rely on Pharmacy doing it correctly and assume it is right’.) The nurse proceeds to tell me that she does her “5 Rights” prior to administration. When I ask her what would happen if she gave the wrong medication that Pharmacy stored in the dispenser, she states she would let her manager know, Pharmacy would be notified, and an incident report would be filled out. Then what would you hope the follow up would be? That the pharmacy manager would find out what happened. This is a perfect example of how the holes in the Swiss cheese line up and the outcome was a medication error. I explain to the nurse the whole model of how errors can happen in healthcare: the fact that each area of the hospital has its own internal processes and all the departments are linked together, and we need to learn the functionality of the processes when we make mistakes. There was no one person responsible for the error-- the organization is accountable to understand and learn from it. The nurse’s responsibility is to do her checks to ensure the medication is correct; if it isn’t, she can contact the pharmacy herself. The pharmacy is responsible to follow up with the tech or staff member who stocked the medication incorrectly. The managers of both the pharmacy and nursing unit find out from each employee if there were any contributing factors, e.g., distractions, competency issues, etc. that played a part in the error. The physician’s responsibility is to inform the patient of any unanticipated outcome. The organization is responsible for understanding its culture of safety and for development strategies that move toward transparency and wanting to learn from mistakes: characteristics of high-reliability organizations. The 10 minutes I spent with that one nurse was valuable to both of us and to her patients. If we want to break down the “walls” we have to be willing to develop relationships with front line staff who, like me, are human – fallible and yearning to do the right thing. We have to look at the systems and the role we play as patient advocates. We are all accountable. Nicola Heslip, RN, BSN, CPHQ, CLNC, CPSO Thoughts to share with Nicola? We will forward them to her. Oil well blow-outs and other disastersThe deep-water oil blow-out and recently capped “leak” (which seems like an inadequate word) in the Gulf is nauseating in its own right when one considers the environmental effects. Because this is a patient safety blog I’ll turn my thoughts a bit to disasters and tragedies and how they make me reflect on safety issues. As I’ve read and thought about space shuttle failures, coal mine disasters, plane crashes, and oil wells some shared themes pop out, grossly simplified as follows: Communication and authority: There were concerns about safety, but there wasn’t an effective way for those concerns to be conveyed to whoever could make a decision to stop, or change the plan – or those who identified the concern did not have the power to stop the process. (I’m not differentiating between perceived or ‘actual’ power – if you don’t think you do, you don’t.) Without trying to figure out exactly what happened, it seems that at least someone was worried about the deep-water oil-drilling technology and yet again, was powerless to take meaningful action. Could they get their concerns to the right ears? Were they pressured to just keep on working? This reminds me of the rationale for a pre-procedural pause and checklist: let’s be sure we listen to everyone, and give their voices equal weight. Blood products? Surgical implant? Special equipment? Critical lab values? Are we all truly ok to proceed? No, something still doesn’t seem right…let’s figure out what it is. Oh, the assistant surgeon can barely keep her rather glassy eyes open and can’t focus. Is she sleep-deprived, upset about something, or otherwise impaired? We need someone else to step in for her. Lack of planning: If you’re drilling an oil well a mile underneath the ocean (where it’s dark and cold and under great pressure, not to mention a non-friendly environment with all those water currents), maybe it would be a good idea to have multiple back-up plans. What’s the worst that can happen? What if something snaps off so oil spews out? An emergency lid or shut-off valve should drop on – has that process been tested in similar setting (in the pitch-black, under a gazillion pounds per square inch, with water moving all around at near-zero degrees)? What if that valve doesn’t activate? What’s the backup plan? And what’s the backup to that? OK, we have a patient who weighs 850 pounds coming in for surgery – we’ll just assume that our lifts and equipments can safely manage him, and that our MRI is of adequate size. Let’s hope that our OR table capacity isn’t actually 500 pounds and that there is a ceiling lift in the ICU just in case we’ll need to move him quickly back to the OR. Priorities: Who is most interested in the risky activity continuing? Who is most likely to push forward, and what are the motivators? Should we delay that space shuttle launch on a very cold morning when the O-rings are getting brittle (which the engineers have made clear previously is a real safety concern) because everyone in the world is watching and it’ll be embarrassing to delay the launch? Should we try to land in heavy fog with every high-ranking person in the Polish government on board because we’re already late for an important ceremony that is a symbol of improved relations between two countries? Coal mines only make money if they are being mined; stoppage time to test the air or drill ventilation holes takes away from productivity. Our fragile patient with heart failure and diabetes is ready for discharge – except she doesn’t seem to understand her medications and her husband is even more frail than she is, and they don’t have a way to get to their next appointment. But she’s stable (a lot more than when she was admitted), she wants to go home, and we do need that bed, as we’re completely full. They’ll do ok…I think they said they have neighbors who help them out. Thoughts? Share with me here. Miriam Marcus-Smith On being a passenger on the way to the NPSF CongressWelcome to the inaugural blog of the Washington Patient Safety Coalition! A dedicated Blog Team will be contributing to this site frequently, so we invite you check back every week or so to see what’s on our minds. We welcome your comments and suggestions for topics. In May I had the opportunity to attend the National Patient Safety Foundation Congress for the first time. I’ll share my two major impressions, one of which is directly related to the event’s content and the other to the process of travelling to Orlando. First, regarding content: my overall impression is that we in Washington are far ahead of the rest of the country. It doesn’t mean that we are perfect or that we are effectively addressing all patient safety issues; rather, over and over I heard activities, partnerships, and interventions described as “innovative!” and “new!” that many in our state have been engaged in for years. Washington’s unusual is that we have a very long history of collaborative work among partners in quality and safety, in combinations and effectiveness not seen elsewhere. This realization was both reassuring and distressing. Second, I flew to Orlando on my airline of choice, Alaska Air. It’s literally been years since I’ve been on another airline. Once we were all boarded at SeaTac, the pilot announced that we might even leave 15 minutes early (woo-hoo!), so I settled into my book and lost track of time…until he announced that we “may have noticed” that we were still at the gate. Well, I hadn’t noticed that about 30 minutes had passed (it was a good book: The Girl with the Dragon Tattoo – no, nothing patient safety-related). He gave some explanation along the lines of “A warning light is going off related to [something that sounded really important to me] and this light is in both the main system and the backup systems. Don’t worry, the mechanics are on board working on it. We’ll keep you posted.” My immediate thought: “What was that recent legislation limiting how many hours passengers can be kept on the tarmac--was it four or five? I’ll worry about it if it doesn’t get fixed soon.” I returned to my book. About 15 minutes later: “The mechanics are still working hard on it…they haven’t figured it out yet…they have their manuals…” Then I started getting worried: At what point would the pressure to depart (keeping on time, avoiding mass unhappiness of the passengers, make sure the crew didn’t go over their work-hour limits) overwhelm the responsibility to do the fix, of whatever it was, correctly? How would the mechanics know that the problem was really fixed? What were they experiencing? Were they all well-trained and rested? Were they at the beginning or end of their shifts? Did they have the tools and information they needed? Were they getting any pressure—either implicit or explicit—to get things done “well enough” to leave close to on-time? (Does this remind you of concerns that might arise with starting that OR case on time, discharging a patient to a SNF, waiting for an interpreter so that the plan of care can be discussed or a consent obtained, or maybe even washing one’s hands?) And what exactly was the problem that to me, being completely ignorant of airplane stuff, sounded very important? Maybe it only sounded critical, and only to me. When I’m on the plane, everything that’s ‘wrong’ sounds equally important to me. Was it the equivalent of a broken brake-light on a car? Yes, it should be fixed, but isn’t going to keep my brakes from working well. Could the pilot have conveyed the information and updates in a better way to the passengers? Short-term outcome: Whatever the problem was, it was fixed to the satisfaction of somebody – the mechanics? The pilots? Who decided? Was it “good enough” or was it perfect? What was the definition of “fixed”? We took off, flew, and landed safely, about an hour late. What I learned relative to patient safety: (1) People who work in our field know too much to be flying around alert and unsedated. (2) We need to be extra-mindful of the pressures on providers. (3) What and how we tell patients and their families is so very important. What if the pilot had said something like this: “There is a problem with System X, which does Y [decorative, important, very important, critical!] function on this plane. We have two well-rested and highly-experienced mechanics on board working on it. If they have any questions, they have other resources they can, and will, contact. They will not allow us to leave until both we and they are satisfied it is safe to do so, no matter how long it takes and no matter how anxious we might all be to get to our destination. This is understood up and down the Alaska chain of command. If you have any questions about this, just put on your call light.” I would have felt much better. Thoughts? Share with me here. Miriam Marcus-Smith
**The opinions expressed by the bloggers here are theirs alone, and do not reflect the opinions of the Foundation for Health Care Quality, Washington Patient Safety Coalition, the bloggers' employers or any other blogger. The Coalition is not responsible for the accuracy of any of the information supplied by the bloggers. The Coalition's bloggers have the best intentions and do not intend to cause any harm to the reader; and they are not responsible for any offence caused inadvertently through interpretation of grammar, punctuation or language. |
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