# NCPS TIPS -- May/June 2005

### Contents: 1. What Keeps You Awake at Night?

2.  Read-Back -- It's Not Just for Nursing Units

3.  Hand Hygiene and Diarrheal Diseases in Healthcare Settings

4.  Safety Spotlight: Telephone Triage Protocol

### 1. What Keeps You Awake at Night?

By Caryl Lee, RN, MSN, NCPS program manager, and Tina Nudell, MS, NCPS
instructional systems specialist

In May 2003 and several times in 2004, NCPS conducted day-long patient
safety training sessions for VA facility leadership teams.

Directors, chiefs of staff, nurse executives, patient safety managers
and other administrative and clinical leaders participated in these
sessions.

The participants listened to presentations about patient safety and
human factors engineering. A number of special topics were also
discussed, such as the 38 USC 5705 confidentiality regulations, business
case for patient safety, and physical plant assessment.

The leadership teams also participated in roundtable discussions.
Several key questions were used as a basis of these discussions,
including:

1.  What keeps you up at night?

2.  What are the most valuable patient safety initiatives implemented at
    your facilities?

3.  What are your strategies for changing the safety culture in your
    facility?

4.  How can the quality and value of root cause analyses (RCAs) be
    improved?

5.  What are your strategies for providing patient safety education for
    trainees (medical residents/students, nursing and allied health
    students) at your facility?

Among a broad range of responses to each question, we found enough
similarities to condense the responses into meaningful categories.

Those who participated in roundtable discussions during the patient
safety training sessions for VA facility leadership teams discussed a
number of issues. Among the broad range of responses to several specific
questions, enough similarities were found to condense the responses into
meaningful categories. Below is how these VHA leaders answered five
specific questions.

How do these answers measure up to your experiences and opinions? Do
they generate new ideas for you as they did for the VHA leaders?

**What keeps you awake at night?** (Total responses: 102)

> 26% Patient care issues (e.g., adverse events)
>
> 25% Increased pressures regarding resources and staffing (e.g.,
> adequate resources)
>
> 23% Communication issues (e.g., under-reporting of events)
>
> 11% Culture issues (e.g., how to move to \"no fault\")
>
> 10% RCA process issues (e.g., implementing follow-up of actions)
>
> 5% General safety concerns/disaster/other

**What are the most valuable patient safety initiatives implemented at
your facilities?** (Total responses: 119)

> 45% Initiatives related to specific types of events
>
> 31% Falls 7% Missing patient
>
> 28% Meds 6% Suicide
>
> 15% Surgery 4% Diagnostics/lab
>
> 9% Mis-identification
>
> 19% Getting word out (e.g., town meetings, environmental rounds,
> newsletters)
>
> 12% Use of Human Factors Engineering, HFMEA, RCA
>
> 8% Event/close call reporting (e.g., anonymous hotline)
>
> 7% Equipment/physical plant changes (e.g., alarms)
>
> 5% Work process changes (e.g., streamline)
>
> 4% Computerization (e.g., alerts, reminders)

**How can the quality and value of RCAs be improved?** (Total responses
= 108)

> 30% Improve RCA team selection and training, reward reporting, reward
> RCA team members
>
> 27% Leadership endorsement of RCA process (and share RCA successes)
>
> 22% Improve implementation, tracking and evaluation of actions
>
> 15% Improve RCA technical aspects and timeliness
>
> 4% Continued NCPS support, feedback and recommendations
>
> 2% Other

**What are your strategies for changing the safety culture in your
facility?** (Total responses = 137)

> 35% Training/getting word out (e.g., newsletters, lunch-and-learn,
> in-service education)
>
> 30% Patient safety structure/process built in (e.g., patient safety
> built into strategic plan, patient safety manager participates in
> purchasing decisions)
>
> 24% Leadership tactics (e.g., environmental rounds, making patient
> safety the first agenda item in \"morning report\")
>
> 6% Rewards (e.g., on-the-spot awards)
>
> 5% Focus away from blame (e.g., prevention not punishment)

**What are your ideas/strategies for providing patient safety education
for trainees (medical, nursing and other professions) at your
facility?** (Total responses = 131)

> 48% Annual, mandatory, and ongoing training
>
> 17% Brochures/handbooks/badge attachments/newsletters/posters
>
> 14% On-line computer self-study
>
> 14% Lectures, in-services
>
> 10% Patient Safety Fairs
>
> 10% "Just-In-Time" training
>
> 8% Staff meetings/M&Ms/AM report
>
> 8% Rounds
>
> 8% Ongoing training
>
> 6% Surveys
>
> 3% Videos
>
> 2% Simulations
>
> 23% Specific training/orientation (e.g., new employee, resident,
> customized)
>
> 11% Leadership (e.g., executive buy-in)
>
> 8% RCA team participation/feedback (e.g., include trainees)
>
> 6% Other
>
> 2% School curriculum
>
> 2% Employee recognition/rewards/incentives

**2. Read-Back -- It's Not Just for Nursing Units**

#### By Mary Burkhardt, MS, RPh, NCPS program manager

Mr. Smith was sent for a CT scan in the afternoon on an emergency basis.
Because of a previous minor reaction to contrast media the provider
phoned in a pre-treatment medication.

The provider called the technician, who took the phone order, and the
patient received the medication before the procedure. Upon reviewing the
treatment records after the fact, the provider realized that while there
had been no harm to the patient, the wrong drug had been given as a
pre-treatment.

The patient safety manager reviewed this medication event report and
realized that there had been a communication failure during a verbal
order for the medication, which involved a sound-alike medication.
Neither "Read-back" nor "Repeat-back" had been used.

The PSM realized that despite the fact that the diagnostic areas of the
hospital (such as radiology, cardiac catheterization lab, nuclear
medicine, and endoscopy) are active patient care areas, no one had
thought to implement the JCAHO patient safety goals dealing with
high-risk communication in these areas. Many therapies, tests and
medications are ordered there which may require the use of phone orders,
patient identification procedures, hand hygiene practices, and
administration of high alert drugs.

Inpatient care areas such as medical surgical, behavioral health, etc.,
are often the routine focus of patient safety educational programs and
awareness campaigns. However, patient safety initiatives often span
across other departments and functions, so it is easy to understand how
some areas might be overlooked.

In this case, the PSM brought the issue to the patient safety committee,
and the diagnostic areas implemented "Read-back." A representative from
those areas was added to the committee. The patient safety committee
subsequently developed a check list of "areas" and "functions" to
proactively assure that no area would be left out of future patient
safety initiatives.

Have any areas of your facility fallen below the radar screen?

**3. Hand Hygiene and Diarrheal Diseases in Healthcare Settings**

*By Noel Eldridge, MS, NCPS executive officer, and Linda Danko, RN, MSN,
VHA infectious diseases clinical program coordinator*

The CDC, and other organizations that have followed their lead, such as
JCAHO and VA, have put increasing emphasis on the importance of the use
of alcohol-based hand rubs by caregivers and other staff members working
in healthcare settings.

Although using an alcohol-based hand rub is usually the best way to
routinely decontaminate hands, there are particular times when washing
with soap and water and increasing the use of gloves are the best ways
to prevent healthcare-associated infections.

This is the case for Norovirus and Clostridium difficile (also known as
Norwalk-type virus and C. diff), two important pathogens against which
alcohol-based hand rubs are not generally effective. These pathogens are
frequently the cause of serious cases of diarrhea in healthcare
settings. Both Norovirus and C. diff can create facility-level outbreaks
and lead to significant illness or death, especially in patients who are
already immunocompromised or frail.

On the microscopic or molecular level, Norovirus and C. diff have
surface properties that make them very difficult to kill with alcohol or
many other antimicrobial compounds used in hand hygiene products.
Because of this, the use of gloves should be emphasized to reduce the
likelihood of these infectious agents accumulating on caregivers' hands.
The most effective way to eliminate them is to wash them down the drain
using soap and water.

The detection, diagnosis, and treatment of diarrheal diseases, such as
those caused by Norovirus or C. diff, is beyond the scope of this
article. For further information, VHA has issued an information letter
on Norovirus:
[*vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=757*](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=757).
A VHA information letter on C. diff is being drafted. Excellent
resources are available online at the CDC Web site:
[*http://www.cdc.gov/ncidod/hip/gastro/ClostridiumDifficile.htm*](http://www.cdc.gov/ncidod/hip/gastro/ClostridiumDifficile.htm).

For both pathogens, special environmental cleaning and disinfecting of
potentially contaminated surfaces is also required. The focus of this
effort is on high-touch areas such as: doorknobs, light switches, faucet
handles, bedrails, wall areas around the toilet in patients' rooms, and
edges of privacy curtains. Areas such as these may have been
contaminated with feces or touched by symptomatic patients or their
caregivers.

When the transmission of C. diff or Norovirus is of concern, the
CDC-recommended approach to environmental infection control is
meticulous cleaning followed by disinfection using an EPA-registered
hypochlorite-based disinfectant as appropriate. Generic sources of
hypochlorite (e.g., household chlorine bleach) may also be appropriately
diluted and used. Additional guidance on cleaning and disinfection is
available at the CDC Web site noted above.

Norovirus is the most common cause of acute gastroenteritis in the
United States. In addition to diarrhea, Norovirus causes other
gastrointestinal symptoms such as nausea and vomiting. Norovirus is
spread by the fecal/oral route.

Because virus particles are present in feces, some particles can make
the trip from fecal matter to bedding, commodes, or other surfaces. From
these locations, the particles can be picked up on the hands of
caregivers or other staff members; worse, directly to mouths of
caregivers or patients.

Unlike many other viruses, a relatively small number of Norovirus
particles can cause illness, possibly as few as 10 particles. A special
concern about Norovirus is that those infected can continue to shed
virus particles in their stool after acute symptoms dissipate. Further,
Norovirus outbreaks in healthcare settings can originate from infected
food workers just as easily as from new inpatients. The CDC reports that
a majority of all Norovirus infections are food-borne.

C. diff is a bacterium that is the most frequently identified cause of
healthcare-acquired diarrhea. In the majority of cases, it is
transmitted to a patient during an inpatient stay; in rare cases, it is
found in a patient's normal intestinal flora, especially infants and
very young children.

C. diff often thrives when certain antibiotics are used to kill other
bacteria that are present in the body. The antibiotics kill the bacteria
that normally protect against C. diff in the colon. If the patient is
then exposed to the C. diff bacteria, it grows rapidly. The increasing
population of bacteria produces toxins that become present in the colon
at a sufficient concentration to cause serious illness (a form of
colitis) that can be life-threatening if not addressed.

C. diff. spores can persist in the environment for many months. The two
major reservoirs of C. diff are infected humans (symptomatic or
asymptomatic) and inanimate objects. Patients exhibiting symptoms of
diarrhea are thought to be the most significant source of new
infections. The hands of caregivers are thought to be the primary way
that the bacteria are spread from one patient to another.

In summary, Norovirus and C. diff are exceptions to the general rule
that pathogenic microorganisms can be removed more effectively with
alcohol-based hand rubs than hand washing with soap and water. When
diarrheal diseases are present in healthcare settings and Norovirus or
C. diff are suspected, hand hygiene should be focused on two main areas:

(1) increased use of gloves to protect hands from contamination; and

(2) the use of hand washing with soap and water to decontaminate the
    caregivers' hands.

*The authors would like to acknowledge Dr. Dale Gerding, VAMC Hines, and
Victoria Davey, VHA Office of Public Health and Environmental Hazards,
who contributed to the content of this article.*

**4. Safety Spotlight: Telephone Triage Protocol**

A patient called a facility\'s telephone triage line to complain of
shortness of breath, tightness in his chest, and pain in the left
shoulder. The triage provider instructed the patient to call back if
symptoms became markedly worse or did not improve. Primary care was
alerted to schedule an appointment for the patient, a deviation from the
telephone triage protocol. If the triage protocol had been strictly
followed, the complaint of shortness of breath and shoulder pain would
have been managed as chest pain, resulting in immediate referral.

Four days later, the patient again called telephone triage with
identical complaints. The disposition of the second call was again
non-emergent, with instructions to call back if symptoms became markedly
worse or did not improve. Again, if the triage protocol had been
followed, the complaint of shortness of breath and shoulder pain would
have been managed as chest pain.

The following day, the patient went to his local, non-VA emergency room
with complaints of shortness of breath and lung pain. Upon being
examined, the patient coded, suffering an acute myocardial infarction.

**Root Cause/Contributing Factors**

Root cause/contributing factors (1): The lack of a barrier to prevent
deviations from the telephone triage protocol can result in an
incorrect, less urgent disposition.

The telephone triage protocol contains references to a chest pain
management protocol for symptoms such as shortness of breath, tightness
in the chest and shoulder pain. No forcing function or barrier, however,
exits within the telephone triage documentation system to prevent
deviations from the protocol. This can result in a less urgent
disposition than appropriate; plus, it increases the likelihood that
possible deviations from the protocol will not be brought to the
attention of a telephone triage provider.

Root cause/contributing factors (2): A second call for same complaint
was not correctly prioritized.

The second call for the same primary complaints and symptoms was not
assigned a higher priority level for immediate intervention. Policy and
procedure in telephone triage did not provide clear step-by-step
instructions for prioritizing a second call for the same complaint. This
increased the likelihood that a second call would not trigger a more
urgent disposition.

**The Five Rules of Causation**

The team followed the Five Rules of Causation
([*www.va.gov/ncps/CogAids/RCA/index.html*](http://www.va.gov/ncps/CogAids/RCA/index.html))
to focus on how and why these events occurred, rather than on who was
involved. The rules provide a systems-based approach to understanding
the root causes of adverse events, moving caregivers beyond the
simplistic "name and blame" culture of the past.

Rule three states that each human error must have a preceding cause,
leading the team beyond the caregivers' involvement to the structure of
the telephone triage system.

Further, rule four states that violations of procedures are not root
causes; they must have a preceding cause. In the old days, an
investigation into such events might well have ended with a
wrong-headed, blame-based solution, such as: "The telephone triage
provider did not correctly follow the protocol."

**Actions Taken and Recommended**

Based on the lack of forcing functions and barriers, the RCA team\'s
first recommendation was to pilot test and implement an electronic
telephone triage documentation and decision support system.

Such interactive decision support systems for telephone triage are
designed to prevent protocol deviations and can decrease the likelihood
of adverse events. For instance, when a telephone triage provider enters
symptoms into this type of support system, the system automatically
designates patient care or evaluation. Some examples of this are: "call
911 now," or "seek emergency care now," or "seek urgent care within
two-to-four hours."

The team also recommended a telephone triage Quality Assurance (QA)
monitor to review and track deviations from the protocol and provide
feedback to practitioners for performance improvements. To measure the
effectiveness, it was recommended that random chart audits of records in
the QA monitor be conducted;

further, that all staff audited be provided with timely feedback based
on the findings.

Pertaining to the second call, the RCA team recommended high-priority
"targeted education" concerning the chest pain protocol and
communication between caregiver and patient.

The team also recommended that policy and procedure for telephone triage
be revised to include clear, step-by-step instructions for prioritizing
the disposition of a second telephone triage call for the same primary
compliant. Further, the team recommended that all appropriate staff
members receive in-service training.

The RCA team\'s recommendations on the second call do not include the
mention of forcing functions, such as are used in decision support
systems. Because these recommendations rely strictly on policies,
procedures and individual actions, they should be considered weak.