# NCPS TIPS -- January 2001

### Contents: 1. Welcome

> 2\. VA & NASA -- "Partners for Safety"
>
> 3\. Patient Safety Alerts
>
> 4\. Facility Feedback
>
> 5\. The Grapevine
>
> 6\. Safety Spotlight
>
> 7\. NCPS Rolls Out New Software
>
> 8\. Salt Lake City Starts Rewards Program
>
> 9\. Learning Links

### 

### 1. WELCOME

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

Welcome to the VA National Center for Patient Safety's new newsletter
--- NCPS TIPS! As you can tell from our nameplate, TIPS is an acronym
for "Topics In Patient Safety." Our objective with this publication is
to bring you useful and timely topics concerning patient safety.

For NCPS TIPS to be successful we're asking for your help in giving us
feedback. Please contact us with any questions, comments or articles you
would like included in future issues. Phone us at (734) 930-5890 or
e-mail us at ncpstips@med.va.gov.

Your feedback is very important to us \-- keep those cards and letters
coming!

### 2. VA & NASA -- "PARTNERS FOR SAFETY"

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

As many of you know, VA formed an agreement with NASA last May to
develop a Patient Safety Reporting System (PSRS) for the VA. This
system's guiding principles are voluntary participation, confidentiality
protection, and non-punitive reporting and is designed to be a
complementary external system to our current internal reporting system.

NCPS and NASA have been steadily working on the design and development
of this system and we are set to begin pilot testing PSRS early this
year at a few VA medical centers. We plan to have the entire system
running by the beginning of FY2002.

NASA is using its experience from developing and running its highly
successful Aviation Safety Reporting System (ASRS). NASA developed and
has been running this system for the Federal Aviation Administration
since 1976. ASRS has been lauded for its strict confidentiality
procedures, managed reports, database created for the easy retrieval of
information, creation of safety products and distribution of safety
information. Their knowledge and experience in this area will be applied
to PSRS.

Please remember that PSRS **does not** replace our current internal
reporting system. As was stated earlier, PSRS is designed to be a
*complementary* system to our internal reporting system. PSRS will
identify vulnerabilities, but not provide detailed solutions as is the
case with events that are reported internally and subjected to our Root
Cause Analysis system.

### 3. PATIENT SAFETY ALERTS

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

To check out the latest VHA Patient Safety Alerts visit
<http://vaww.ncps.med.va.gov/alerts.html>.

### 4. FACILITY FEEDBACK

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

(Patient safety feedback from throughout the VHA. Please send any
comments you'd like to share with us to ncpstips@med.va.gov.)

***IG Visit***

We recently had a visit from the IG (they had 23 on-site) that went very
well. The IG staff were aware of the RCA process, and were very
impressed with the actual implementation at our medical center. They
requested RCAs in advance and also reviewed them on site. They commended
the work that had been done and spoke very highly of the process. The IG
wanted proof that there had been follow up from the action items and
asked to see measures associated with the RCAs, which we were able to
show them.

***\--Carol Biggs***

***South Texas VHCS***

***Joint RCA***

We are incorporating an aggregate RCA into a joint process action team
(PAT) with our staff and staff from Tripler Army Medical Center (TAMC),
with whom we have a sharing agreement. We have identified skin breakdown
issues with patients transferring between our Center for Aging and
Tripler's inpatient med/surg. units \... Our COS, Director, and myself
felt it was necessary to have people from Tripler help us address these
issues through a PAT. The charter memo states the following: 1) conduct
an aggregate RCA on 6 current TAMC/VA cases that have resulted in
negative outcomes related to skin breakdown; 2) from this review,
develop/implement a uniform assessment and documentation process to be
applied throughout the federal medical campus; 3) implement practice
guidelines related to the prevention and management of skin ulcerations;
4) develop a conjoint review process to assure that reviews are
occurring when relevant; and 5) describe the review process, aggregation
of data and reporting mechanisms. Getting the joint team together, at
the same time as trying to promote a non-punitive culture has been very
challenging, but has finally happened. The team convened recently and
JIT training has taken place.

We also just completed a CARF survey for some of our mental health
programs. The CARF surveyors were briefed on the RCA process and given
some examples of how it has been implemented within the facility. The
CARF team complimented us on having an exemplary integrated risk
management program with great emphasis on patient safety and improvement
activities.

***\--Cheryl Taylor***

***Honolulu VAMROC***

### 

### 

### 5. THE GRAPEVINE \-- NOTES FROM THE NCPS STAFF

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

-   Many facilities are not meeting the 45-day RCA completion time
    frame. In many cases this is due to the large number of individuals
    involved in the review and approval of the Charter Memo and the RCA
    report. On the front end when issuing the Charter Memo it is
    critical that supervisors of the respective team members be
    consulted. However, to facilitate the process, we recommend that
    this be done informally using the telephone or electronic mail.
    Having each supervisor individually review and concur with the
    Charter Memo builds in unnecessary delay.

> Only the team members, advisor, and Director (or equivalent) need be
> involved in the RCA report signature process. While we strongly
> encourage advisors to have RCA teams consult with those individuals
> tasked in Table 19 with completing the actions, a formal signature
> process impedes completing the report. Remember that no one, with the
> exception of the Director, has veto authority over the team's
> recommendations. The important point is to get the report completed
> and the recommendations implemented as soon as possible to prevent the
> adverse event from recurring. Please review and streamline your
> process.

-   Facilities are returning RCA reports to RCA teams for correction of
    *typograficla* errors or to enhance the appearance of the flow
    charts. This is NOT necessary! We in NCPS are concerned with the
    content of the report, not its appearance. The important point is to
    implement the actions.

### 

### 

### 6. 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.)

#### Description 

A patient was being prepared for a CT scan in a busy, noisy, crowded
room. The telephone was ringing, multiple staff were present, and the
scans were running behind schedule. Patients were doubled up in the
preparation room, in an attempt to speed up the process and to address
the backlog. Two CT techs were sharing the duties of preparing the
patients, moving as fast as they could so as not to slow down the
process.

One of the CT techs took the next patient and prepared to use the power
injector to inject contrast prior to the CT. Tech #2 arrived after Tech
#1 had left for another area. Seeing the syringe plunger extended and
the chamber nose down, he assumed that the power injector had been
reloaded. Tech #2 proceeded with the scan, injecting approximately 150
ml of air into the patient. Initially the clinical staff assumed the
problem was anaphylaxis. Further review identified the true problem and
appropriate actions were taken. The patient survived with no permanent
adverse outcome.

#### Vulnerabilities

-   In this instance there were numerous vulnerabilities and system
    weaknesses present:

-   The design of this equipment lends itself to such errors.

-   There is no lockout device preventing using the machine without a
    full syringe.

-   In addition, the design of the prep room contributed to an
    environment conducive to error, as was the pressure to expedite the
    scans.

-   Finally, the division of duties between the two techs led to a
    potential to fail to communicate about the status of the patients
    and their procedures.

#### Actions Taken

-   In response to this case, the facility took the following actions:

-   Developed interim plan to reduce traffic and phone calls in the CT
    control room.

-   Addressed work volume and staffing issues.

-   Educated staff on signs and symptoms of air emboli.

-   Investigated the availability of alternative equipment with lock out
    features.

-   Identified and ultimately purchased power injector with lockout
    feature preventing air injection.

### 

### 

### 7. NCPS ROLLS OUT IMPROVED SOFTWARE

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

NCPS will soon be implementing improved software for the RCA process and
patient activities. The software, called SPOT, is now being used and
evaluated in Florida VAMCs. We will be refining training materials,
improving design, and finding/fixing any incompatibilities.

We anticipate that in the next several weeks these issues will be
addressed and we will begin roll out to other networks. In general, we
will be installing (rolling out) the patient safety software in the same
sequence as the networks were trained last year.

The new software will have many new and useful functions. RCA cases will
now be sent securely, electronically, and nearly immediately. Flowcharts
can be automatically drawn and edited from text outlines. Previous RCA
cases can be searched. Finally, on-line help and automation is built
into the RCA data entry.

### 8. SALT LAKE CITY STARTS REWARDS PROGRAM

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

The Salt Lake City VAMC has initiated several actions that substantially
and positively impact the patient safety program within their facility.
Team members on RCAs receive letters signed by the Facility Director and
the Chief of Staff congratulating their involvement and outlining the
actions that will be taken based on the RCA recommendations, as well as
a special contribution award.

They have taken the incentive program a step further so that anyone who
reports an adverse event that is then the basis for an RCA also receives
a special contribution award of \$100. At the close of the RCA, the
person who reported the incident also receives a letter of thanks from
the Patient Safety Improvement Coordinator outlining the corrective
actions that will be taken. Pamela Bennett, Patient Safety Improvement
Coordinator, and Valerie Robinson, Quality Management Director,
initiated and coordinate this new rewards program.

In the vein of the learning organization, SLC staff seek out feedback
and suggestions for improvement from each team member after each RCA
through a simple survey (see our website for example of the survey). The
results?

-   100% strongly agree the RCA process was valuable and time allocated
    sufficient.

-   100% strongly agree or agree that able to identify root
    causes/contributing factors for event, able to develop meaningful
    recommendations, found participation in the RCA process valuable,
    and felt the team worked efficiently.

### 9. LEARNING LINKS

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

Each issue we'll try to highlight a web site that we think is
informative and innovative.

This issue's site is "Bad Human Factors Designs" at www.baddesigns.com.
It is a scrapbook of illustrated examples of things that are hard to use
because they do not follow human factors principles.

Check it out and let us know of any web sites that you think we should
include in future issues.