Archive for December, 2011

It always boils down to communication

A recent incident in which three people, including one child, was infected with hepatitis C through transplanted tissue just highlights, yet again, the importance of communication to achieve patient safety, no matter whether it’s between colleagues who work together every day or organizations hundreds of miles apart that never (usually) have a reason to communicate.

The tissue was implanted in the child after it was discovered the organ donor had infected another person. Eight days after.

Two days after the implantation, the CDC was notified.

I think the lesson here is communicate early, communicate often, and when in doubt, communicate some more. Providers are busy, and often move communication to a lower priority than it should be. Communication makes the world go round, gets work done, and gets it done right. Even the pathways of how each participant plans to communicate (e-mail, phone, etc.) should be decided ahead of time when it’s really important—and in healthcare, it’s often really important.

Adverse events always remind me of an activity we used to do at camp when I was a child. As part of “outdoor adventure,” we’d often take hikes, go canoeing, and enjoy nature. It also provided team building and safety education. One of the activities that promoted these teachings was the Trust Fall:

A person stands on top of a platform above everyone else, who form a “net” with their arms and hands by facing each other in two parallel lines and linking arms, forearms up. The faller stands on the platform, at the edge, back toward everyone else, arms crossed over chest. The idea is that this person will fall backward into the net, trusting that everyone will catch him or her. The activity shows that if you are careful and follow proper protocol, you can trust your team to keep you safe, even when facing the unknown or scary. (As you might imagine, it’s very difficult to allow yourself to simply fall backward.)

The protocol of communication begins once everyone is in place:

Faller: Falling!

Catchers: Fall away!

Only until this communication occurs does the faller fall.

This type of communication, of course also used in many other industries, needs to be far more common in healthcare, among colleagues and among hospitals across the nation.

The hospital about to use the tissue could have checked one more time (“Falling!”) with the transplant center (“Fall away!” or, in this case, “Stop!”). A method for that kind of check needs to be implemented. A real-time online database that can be updated directly by transplant centers and checked immediately before surgery at the recipient’s hospital should exist. I think many patients already assume it does.

Patients should be able trust the healthcare system and its protocol, even when facing the unknown or scary.

Joint Commission suggests “strategic caffeine consumption” as part of Alert

The Joint Commission issued a Sentinel Event Alert on healthcare worker fatigue and its effect on patient safety on December 14, 2011.

Of course, fatigue is a serious and prominent problem among healthcare workers. According to the Alert, a November 2007 issue of The Joint Commission Journal on Quality and Patient Safety found that nurses who work more than 12-hour shifts and residents working recurrent 24-hour shifts had three times more fatigue-related preventable adverse events.

So what can be done?

The Joint Commission recommends reviewing off-shift hours, consecutive shifts, and staffing levels, and involving frontline staff in creating practical solutions. It also advised taking a close look at handoffs, perhaps even putting in some methods during at-risk handoff times when staff may be particularly tired, relying on teamwork during at-risk time periods, and educating staff on good sleep habits.

Notably, The Joint Commission also wants hospitals to consider fatigue as a possible factor when reviewing adverse events—do you do this currently? When reporting an event, do you ensure to note fatigue if it was a potential factor? Such data would be interesting to understand how to improve healthcare across the nation.

Also of note, The Joint Commission officially asks hospitals to create a “fatigue management plan” which should include “strategic caffeine consumption and short naps.”

Pretty practical advice. If you’re looking for some evidence-based method of drinking coffee and napping, you might want to take a look at a recent report that says drinking a cup of coffee, then taking a 15-minute nap, is the best way to go. This way, you wake up just as the caffeine starts to kick in. Well, that’s the idea anyway.

Drink up and sleep tight!

Texting while rounding :(

Everyone knows that texting while driving is dangerous—and illegal in many states. It’s obvious why: The driver gets distracted and takes his or her eyes–and mind–off the road.

But what about frontline care staff? Can they text on the floor? If so, when? Does your hospital have guidelines about this? Many hospitals are worried about the content of texts and other uses of social media, such as Facebook. They worry HIPAA will be violated. But a recent incident exposed on the AHRQ’s “morbidity and mortality rounds on the web” proves that texting while rounding, no matter what the content, can prove distracting and near disastrous, especially when smartphones serve as both a hospital tool for ordering medication and the portal to a resident’s social life.

The case involves a resident and intern who discussed the plan of care for a patient while rounding. An attending told the resident to stop warfarin until an echocardiogram of the heart could be taken.

Here’s a key part to this case: The hospital’s CPOE system allows providers to enter orders in the system through smartphones, a convenient option that allows real-time ordering. The resident began submitting the orders on her smartphone. Then she got a text about an upcoming party. The resident chose to respond to the text. The order for the patient was never completed, and the patient continued to receive warfarin for three days. Because of the CPOE system, no one reviewed the medication list, and everyone thought the order for warfarin was stopped. Though not stated in the case, I’m sure at least some of them thought they actually saw the resident put through the order on her phone.

The problem was realized when the patient developed shortness of breath, tachycardia, and hypotension from blood thinning. He needed emergency open heart surgery, and was in the hospital for three weeks before being discharged.

For those who use smartphones, it’s incredibly easy to understand how this happened. Once the decision is made to view a text (or if it pops up automatically), you are interrupted. Your screen is filled with only this text. You reply. Thoughts are now with that conversation, and there is nothing to remind you that another application is open, that you never finished the task.

Mobile devices and social media have brought personal lives into the workplace. However, when the finished product is a healthy patient, we need stringent rules for such devices. A personal phone call regarding a party would never be allowed on rounds. Nor would her friends, decked in party hats, be allowed to show up in person to disrupt her to find out whether she’s coming. But these scenarios are very similar to texting; you are communicating with others outside of your work, which brings thoughts elsewhere. Forget call lights and pages, this is the ultimate distraction because it’s intimate, private, easily hidden, and has absolutely nothing to do with work. Despite what we want to believe, no one can do two things at once, no matter how many apps you have.

It may be time to consider whether it makes sense to allow work and play to be conducted on the same device in healthcare. Mobile technology has many benefits, but perhaps the mobile devices staff use in the hospital to submit orders should be different than the devices they use to manage their social life. Many workplaces see this as a matter of etiquette. They trust employees to limit personal use of mobile devices during work hours. However, when you’re talking about the difference between sending a smiley face to confirm you’re attending tomorrow night’s party and submitting orders to stop an anticoagulant for a patient in danger of excessive blood thinning, you’re talking about much  more than etiquette.

What do you think? What are your hospital’s guidelines on this?

Joint Commission proposes new goal to prevent harm, waste

Last week, The Joint Commission announced it was proposing a new National Patient Safety Goal. The goal would address overuse of treatments, procedures, and tests.

The idea is that if evidence shows no benefit, you are exposing a patient to only potential harm by giving an unnecessary test or treatment.

The proposed goal would have hospitals implement a program to   address the issue by selecting a treatment or test to focus on. Pick something, evaluate it, monitor it, and implement new methods to decrease any overuse that’s found.

I find this proposed goal an interesting one. The other goals impose measures to decrease the risk of harm, but the risk here seems more minimal or evidence-based. I don’t mean to say there aren’t risks, I’ve discussed the risks of too much radiation over time, but there is no denying this goal would also reduce waste and cost, and those effects will be much easier to measure. Was this designed to back up physicians who don’t order a test for everything for fear of malpractice suits? Would this help if a physician was charged with negligence for not ordering a test that was not necessary but, as it turns out, would have discovered something?

What do you think of the proposed goal? Post your comments below.

And by the way, the The Joint Commission is taking comments until January 24!