# NCPS TIPS -- July/August 2001

### Contents: 1. SPOT Update

> 2\. Psychiatric Ward Screens
>
> 3\. VA Salt Lake City Develops Community Collaborative Partnership
>
> 4\. Oral Medication Syringes
>
> 5\. Safety Spotlight
>
> 6\. RCA Team Tips

### 

### 1. SPOT UPDATE

##### From the VA National Center for Patient Safety

SPOT is the root cause analysis (RCA) software that will replace the
Microsoft Word RCA Template. RCA is a key patient safety process to help
VHA healthcare facilities answer these questions about adverse events
and close calls: **what happened?, why did it happen?, and what can we
do about it?**

SPOT is actually a combination of Microsoft (MS) Access database
software and SQL Server software. Much of the RCA data and MS Access
software is stored on a facility's fileserver, which is a network
computer usually located in the main computer area of a hospital. Other
parts of the software are located on the PCs of the risk or patient
safety manager and PCs of other people in their office who lead RCA
processes. With password protection, all these PCs communicate (are
networked) with the fileserver in a secure fashion. In addition, an
individual RCA case can be temporarily downloaded onto a "stand-alone"
laptop computer and used by the RCA team, who use temporary passwords
for that case. Finally, when an RCA case is completed, it can be sent in
a secure fashion to the SQL Server database at NCPS.

**[What are the major capabilities of SPOT?]{.underline}**

\- Guide and support the Risk/Patient Safety Manager and RCA Team
through the process

\- Capture data on safety events and all the items in the RCA Form
presently in use (i.e., 22 questions)

\- Run as shared (network) and stand-alone (laptop) computer set-up

\- Search upon RCAs in your facility

\- Search for deidentified RCAs from all of the VA (this is called
"Search-All")

\- Develop flow charts in an automated fashion (VA NCPS invention)

\- Secure electronic submission of RCAs from facilities to NCPS

\- Tools to follow-up, track, and document corrective actions and
outcome measurement

\- For VISNs, various capabilities to assist VISN patient safety (this
is called "VISN SPOT")

**[When will you see SPOT run?]{.underline}**

January 2001:

\- Phase I roll-out (five sites)

\- Tested software at five facilities in one VISN

April-June 2001:

\- Phase II roll-out (30+ sites)

\- Tested implementation and software issues at one volunteer facility
from the other 21 VISNs

Fall 2001:

\- Phase III roll-out (130+ sites)

\- VISN by VISN accelerated implementation at remaining facilities

Fall-Winter 2001:

\- "VISN SPOT" final development and testing at 22 VISN offices

\- Further enhancements and trouble shooting of SPOTs as necessary (e.g.
"Search-All")

### 2. PSYCHIATRIC WARD SCREENS

##### From the VA National Center for Patient Safety

Some older facilities still have windows in locked psychiatric wards
that were fitted with security screens. Over the years the screens warp
and develop different size gaps between the screen and the window frame.
There are three bolts on each side of the window that hold the screen in
place. There was a recent incident at an inpatient psychiatric ward in
which a psychiatric patient was able to thread a bed sheet around the
middle bolt that holds the screen to the window and create a noose. The
middle bolt is at a height that would allow a person to be hanged. It is
recommended that if you have older buildings housing inpatient
psychiatric patients and the windows are protected by security screens
that you check them for excessive gaps.

### 3. VA SALT LAKE CITY DEVELOPS COMMUNITY COLLABORATIVE PARTNERSHIP

##### From the VA National Center for Patient Safety

The VA Salt Lake City Health Care System (SLCHCS) is working
cooperatively with community agencies to promote patient safety
initiatives throughout the state. The SLCHCS Director, James Floyd, is a
member of the Utah Hospital Association (UHA) Patient Safety Task Force.

Members of the UHA, and representatives from the Utah State Department
of Health, were recent guests at the medical center for a presentation
on the VHA Patient Safety Program and the activities being undertaken at
SLCHCS. This exchange of knowledge and information regarding program
development is anticipated to assist in a statewide rollout of a patient
safety program.

### 4. ORAL MEDICATION SYRINGES

##### From the VA National Center for Patient Safety

We have recently been informed by VISN 16 about a close call involving a
nurse drawing up an oral liquid medication. The nurse was using an oral
medication syringe called a "pipette" by the manufacturer.

The graduated markings on the "pipette" were unlike the markings on the
syringes we commonly use in the USA. Therefore, when using a "pipette"
you need to measure the dose you are administering in a way other than
what you are used to doing. The graduated markings are **on the
plunger** of the 3 ml "pipette" and start at 3 ml on the tip end with
intervals of negative (-) 0.05 ml per division. On the standard USA
syringe the markings are **on the barrel** and start with 0 cc/ml on the
tip end with intervals of positive (+) 0.1 ml per divisions (see
accompanying photos).

**[What Happened]{.underline}**

In this close call the nurse was drawing up a dose of 0.25 mg of an oral
medication liquid (1mg/ml) using a "pipette," but instead of drawing up
0.25 ml of the liquid 2.5 ml (2.5 mg) was drawn and nearly administered
to the patient.

**[Suggestions]{.underline}**

√  Consider using oral tablets.

√  For those inpatients that cannot tolerate tablets, have pharmacy
prepackage unit dose liquid.

√  Caregivers should replace the "pipette" with a USA standard-type oral
syringe (that cannot be attached to a needle or IV tubing to avoid
unintentional administration by wrong route).

√  Alert all staff that pass medication about the "pipettes" and that
these should not be thought of as typical syringes. The markings are
unlike those of the syringes we are used to, and they are on the plunger
of the "pipettes." If possible, **DO NOT USE THEM**.

We are now working with the Institute for Safe Medication Practices
(ISMP) and the "pipette" manufacturer to provide a new pipette that
meets USA standards. Thanks go out to the VISN 16 staff for alerting us
of this potential problem.

### 

### 

### 5. SAFETY SPOTLIGHT

##### From the VA National Center for Patient Safety

(On a regular basis we will feature teaching examples pulled from
medical literature and similar RCAs that we feel are applicable and of
interest to the entire VHA healthcare system. These cases are intended
to be used for learning purposes only.)

### Surgical towels

(We have seen a number of incidents of retained objects in post op, here
is an example of one.)

**[Description]{.underline}**

A patient underwent emergency exploratory surgery for a perforated
ulcer. During the surgery, a non-radiopaque **towel** (that's right - a
towel - not a surgical sponge) was placed in the abdomen to retract the
liver. This was not clearly communicated to the assisting resident or
the nurses. Upon closing, the towel was missed and was left inside the
abdomen. Several days post-op, the patient developed discomfort and
ileus. Abdominal x-rays were done but the towel was not visible since it
had no radiopaque markers. A CT scan was done which revealed free air
and possible retained foreign body. Patient was taken back to the
operating room where an abscess was found around a surgical towel. The
towel was removed, abscess cavity drained, and the patient fully
recovered.

**[Lessons Learned]{.underline}**

The following lessons were learned from this event:

Clear communication between physician and operating room team when
placing materials inside the body cavity is critical.

Familiarity with the facility's operating room policies, specifically
those pertaining to non-radiopaque materials being placed inside the
body cavity, contributed to this event.

Operating room policies did not clearly address use of towels in body
cavities, only making reference to radiopaque sponges, needles and
instruments. Prohibited or high risk categories of objects were not
addressed.

**[Actions Taken]{.underline}**

The following actions were recommended:

 Any materials that are placed inside the body cavity will be clearly
communicated from the surgeon to the scrub nurse with verbal
confirmation from the appropriate OR staff including tracking.

Establish new formal physician orientation to assure physician
knowledge of current policies and procedures.

Revise operating room policies based on current standards of practice
and prohibit the use of any material that is not radiopaque inside the
body cavity unless by specific approval.

### 

### 6. RCA TEAM TIPS

##### From the VA National Center for Patient Safety

The following is a list of helpful hints for those of you involved in
the RCA process.

**[ADVISORS:]{.underline}**

• Attend team meetings and provide clear guidance at critical decision
points (i.e., Initial Flow Chart, Tables 15 & 19).

• Do a final check with the group recorder to ensure that identifiers
(i.e., personal names, facility names) do not appear in flow charts or
narrative text. (This step is critical in initial de-identification of
the patient safety information database.)

• Don't let the team waste time trying to make picture perfect
flowcharts (these can always be done by hand, if necessary). If anyone
experiences difficulty with the software, please contact NCPS right away
at (734) 930-5890 and ask to have a software expert work on the problem
right away (this will save time and minimize frustration).

**[TEAM LEADERS:]{.underline}**

• It is useful for the leader and team members to bring their calendars
to the first meeting and set the schedule for future full-team meetings
right away. Likewise, it's great to have a briefing/sign-off meeting
date with the Director established as soon as the team is chartered.

• Establish clear boundaries with others interested in the RCA process
and actions. Only the Director has the authority to non-concur with an
RCA team action and request a revision to any action. (Do not put
department heads, service chiefs or administrative gatekeepers in the
position of editing, revising or censoring the RCA action plan.)

**[TEAM MEMBERS:]{.underline}**

• Avoid blindsiding your colleagues[!]{.underline} Interview department
heads or service chiefs who are likely to be involved in carrying out
actions early in the RCA process (seek their opinions and experiences
... learn about what has been tried successfully or unsuccessfully
before, and avoid known obstacles.)

• If the team selects an expensive fix (e.g., staffing, equipment, etc.)
do some homework before submitting the plan to the Director (i.e.,
consult with a local fiscal expert in deriving approximate short and
long term costs for the fix).

**[TOP MANAGEMENT TEAM:]{.underline}**

• Schedule a RCA briefing and sign-off date as soon as the RCA team is
chartered. Let the team present the report to management, let them cover
"what we found," the "recommendations" and "what is needed from
management." This will provide an avenue for the team to be recognized
for their work and ensure clearer communication about any additional
work that needs to be done.

• Tell your own stories, and make it safe for others to tell theirs.

These are just a few RCA team tips. For a more thorough listing of RCA
hints visit the "Mining Gold" section on the NCPS intranet site
(http://vaww.ncps.med.va.gov/gold.html).