# NCPS TIPS -- October/November 2001

### Contents: 1. VA/QuIC Patient Safety Summit Gives Attendees Plenty to Take Home

> 2\. Safety Spotlight
>
> 3\. What is HFMEATM
>
> 4\. Cognitive Aids Distributed
>
> 5\. A Chance to Make a Difference ... The Results

### 

### 1. VA/QUIC PATIENT SAFETY SUMMIT GIVES ATTENDEES PLENTY TO TAKE HOME

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

The VA/QuIC Summit on Effective Practices to Improve Patient Safety was
held September 5-7, 2001, in Washington, DC. Approximately 350 people
attended the Summit with about two-thirds coming from VA. With a focus
on presenting information that could put to immediate use to improve
patient safety, the Summit had over 30 different presenters.

One of the featured presenters was Dr. Mark Rosekind, President and
chief scientist at Alertness Solutions and a former sleep research
scientist at NASA. An internationally recognized expert in fatigue
management, sleep, circadian rhythms, and performance, Dr. Rosekind
spoke about alertness management in health care settings. Our circadian
rhythm programs us to sleep at night and to be awake during the day.
When we try and override this through shift work and altered work
schedules, employees encounter fatigue and sleepiness and degraded
vigilance and decision-making. Additionally, Dr. Rosekind discussed the
epidemic proportion of people not receiving sufficient sleep. When this
physiological need for sleep is not met, the human brain can
spontaneously shift to microsleeps (lasting only seconds) to extended
sleep (lasting minutes). Some of the signs and symptoms of fatigue are
slowed reaction time, forgetfulness, fixation, reduced vigilance, and
degraded communication and decision-making skills.

In response to fatigue, Dr. Rosekind presented personal strategies for
coping. Simply telling health care workers to "get more sleep" is not
going to change anything. We need to be aware of fatigue countermeasures
to minimize sleep loss such as naps, good sleep habits, and the effects
of food, alcohol, and exercise. Since sleep debt is cumulative with the
average person needing eight hours, minimize your sleep loss. Naps can
prove enormously helpful; "Any nap beats no nap," states Dr. Rosekind,
with 20 to 45 minutes representing an effective period of nap time. Once
an individual realizes they are fatigued and they cannot get any sleep,
other effective measures include physical activity, social interaction,
and strategic caffeine use. Suggests Dr. Rosekind, "Don't take caffeine
when you are wide awake at the beginning of a shift; instead, take it
before your anticipated time of decreased alertness. Your circadian
rhythm typically makes you the sleepiest from 3 to 5 a.m.; take the
caffeine an hour before this time if you have to be alert and working."

Dr. Rosekind reviewed the first steps that patient safety managers and
leadership should consider in addressing fatigue in operational settings
including:

· Educate people about fatigue and sleep

· Consider setting the number of hours of service for employees

· Be cognizant of physiological needs of employees when scheduling

· Consider countermeasures such as rest areas for employees

For more information on this topic, visit his company's website at
[http://www.alertness-solutions.com/.]{.underline}

Another featured presenter was Major (Dr.) Fred Stone, one of the
principle authors of the U.S. Air Force's Medical Team Management
program, who has trained hundreds of Department of Defense health care
workers around the world on teamwork and patient safety. Major Stone
uses video vignettes and discussion to demonstrate that a lack of
teamwork creates an unsafe and hazardous work environment. A situation
encountered in healthcare is excessive professional courtesy, whereby
those of higher status are deferred to and not questioned even when
there are observed deficiencies in performance. Major Stone presented
the undesirable circumstance of "accommodation," whereby team members
become complacent with difficult tasks (such as complicated surgeries)
because they have performed them so frequently.

There are specific strategies that can be taught to teams that are
effective in countering these tendencies. Whenever anyone "feels the
pinch" (defined as a potentially unsafe situation), Major Stone suggests
a non-threatening assertive statement such as "Doctor, I'm concerned
about the amount of bleeding we're witnessing at the surgical site. Can
we take a moment to confirm that all the sutures are holding?" The "two
challenge" rule can also be agreed to as a strategy by a team. This
involves an agreed to action (such as calling in another person for a
consult), if a medical team member does not respond following two
assertive statements. Additional resources on Major Stone's work will
soon be available on the Air Force's Medical Team Management website,
scheduled to be online in the next few months. We will publish
information about this site in an upcoming TIPS.

Other presentations at the Summit included Institute for Healthcare
Improvement President Dr. Donald Berwick talking on patient safety
improvements, Joint Commission on Accreditation of Healthcare
Organization's (JCAHO) President Dr. Dennis O'Leary talking about JCAHOs
new initiatives for patient safety, and VA National Center for Patient
Safety Director Dr. James Bagian talking about lessons learned about
patient safety in the VA.

The response to the questionnaire distributed at the Summit indicated
that participants were highly satisfied with the program: satisfaction
levels in respondents averaged 90% for 17 different questions surveyed.

Selected summit presentations and materials will be made available on
line at the NCPS internet and intranet sites. When this information is
available on-line, a notification will be sent to Summit registrants and
we will also announce it in TIPS.

### 2. 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 health care system. The following represents
information taken from RCAs; it is presented to spark discussion and
[does not]{.underline} represent NCPS policy. Depending on the specific
circumstances at any given facility, there are various systems-level
solutions that will be most appropriate.)

### Administering a paralytic agent when patient is not on ventilator assistance 

###### Description

Vecuronium was ordered for a patient in SICU who was intubated; two days
later the patient was extubated but the Vecuronium remained as an active
order. A nurse from the ICU was reassigned to the SICU and was assigned
to care for the patient, including administration of medications to him.
The RN noted Vecuronium Bromide on the patient's medication profile in
BCMA and in the Pyxis medication dispensing system. The RN, not familiar
with this particular drug, asked another nurse about the expected
actions of the medication. The nurse responded that Vecuronium is a
paralytic agent. The RN then administered the drug as ordered. The
patient, no longer intubated, experienced a full arrest shortly after
receiving the drug. Chest compressions were started, a code was called,
and the patient was promptly intubated. The resuscitation was successful
and the patient achieved full recovery with no immediate or long lasting
complications reported.

####### [Facility Identified Vulnerabilities]{.underline}

The following are factors that increased the probability of
inadvertently using this paralytic agent:

The CPRS and Pyxis systems provide no warnings regarding neuromuscular
agents and the need to ensure adequate airway before administering

The pharmacy system does not require reordering of neuromuscular
agents within any specified time frame

The CPRS system does not provide easy access to review pharmacological
agents while writing medication orders

There was no clinical pathway for management of ventilator dependent
patients

The system for releasing physician's orders does not ensure that all
orders have been reviewed by a pharmacist or pharmacologist before
release

The competency of RNs assigned to ICUs should be revised to accurately
and specifically support the practice level required in the various
intensive care units

###### Actions Taken by the Facility

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

Neuromuscular agents will now have a three-day automatic stop date

Anesthesia has developed a Quick Reference Guide for maintenance dose
of neuromuscular agents

All pharmacy orders will be approved by a pharmacist or pharmacologist

Clinical reminders for these agents are activated in CPRS when the
medication is prescribed

Chief of Pulmonary developed clinical guidelines for the
administration of paralytic agents

Revised ICU competencies with annual audits to ensure accuracy

###### Staff Observations

Three years ago if this had happened, we would have been looking for
someone to blame. The nurse would have been disciplined at a minimum and
might have been fired.

Once the RCA team began to examine the specifics of this case and delve
into why this occurred and what system issues allowed this incident, we
were quite successful in identifying vulnerabilities that many did not
realize existed. Our team members were excited about their involvement
and felt justifiably proud that they had made a substantive difference
in patient safety.

######## NCPS Comments 

*Some of these specific actions are important and improve the quality of
care delivered, but will not directly mitigate these vulnerabilities.
The team might have also considered limiting the medication dispensing
by staff that have rotated onto the service. Another vulnerability that
might have been considered is the availability on Pyxis floor stock of a
neuromuscular (paralytic) agent. A barrier could be removing these from
the floor and placing in the pharmacy.*

*Under actions taken by the facility, the three-day automatic stop date
may represent a compromise between an unlimited order and a one-time
order. We wonder if other facilities have adopted a variable order date
such that the neuromuscular agent is primarily a one-time or three-day
dose, but perhaps can be written PRN for long-term vent-dependent
patients.*

Depending on the specific circumstances at any given facility, there are
various systems-level solutions that may be of value. In any event, this
case points out how adverse events and close calls can identify
vulnerabilities, that when constructively approached, result in actions
that can reduce the likelihood of similar problems in the future.

### 3. WHAT IS HFMEATM?

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

Healthcare Failure Modes and Effects AnalysisTM (HFMEATM) is a
prospective analysis system developed by NCPS. HFMEATM uses a
multi-disciplinary team, process and sub-process flow diagramming,
failure mode and failure mode cause identification, a hazard scoring
matrix, and a decision tree algorithm to identify system
vulnerabilities. A worksheet is used to record the teams decisions,
rationale and corrective actions.

HFMEATM was introduced by NCPS through a series of four videoconferences
aired this past August. Following these broadcasts a training videotape
was created and shipped to each medical center. The HFMEATM forms and
work sheets have been made available on the NCPS intranet website
(http://vaww.ncps.med.va.gov). The program was also presented at the
VA/QUiC Patient Safety Summit during September 2001.

NCPS will be distributing example analysis of the BCMA contingency plans
using the HFMEATM system during the first quarter of FY02. While the use
of the HFMEATM prospective analysis system is not mandated, it is
recommended.

### 4. COGNITIVE AIDS DISTRIBUTED

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

NCPS recently distributed the first series of cognitive aids to VHA
facilities throughout the country. These aids included an enhanced
version of the American Heart Association's 2000 Handbook of Emergency
Cardiovascular Care, the Malignant Hyperthermia Emergency reference
card, the Association of Anesthesiologists Difficult Airways Algorithm
and a Malignant Hyperthermia poster.

The cognitive aids sent to each location were based upon a survey
conducted during the first quarter of FY01. This survey requested each
facility to identify the number of code carts, the number of anesthesia
machines, and the number of operating rooms at their location, including
CBOCs.

The cognitive aids are intended to serve as a reference and reminder for
clinical staff and assist health care in moving away from a culture that
is totally dependent upon each individual's ability to memorize
difficult and complex tasks for use during routine and crisis
situations.

Demand for the cognitive aids has been high, with many facilities
requesting additional copies. A second order is being processed and
additional sets of the cognitive aids should be available within the
next few months.

We would like to take this opportunity to thank VISNs 6, 17 and 18 for
agreeing to pilot test the distribution of this first sets of aids. The
lessons learned at these facilities helped ensure a smoother role out
for the remainder of the country.

### 

### 5. A CHANCE TO MAKE A DIFFERENCE ... THE RESULTS

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

NCPS thanks all of you that submitted proposals for equipment and
products that improved patient safety and resulted from a root cause
analysis recommendation. A panel reviewed the recommendations on the
basis of generalized applicability to a broad group of VA hospitals,
documented patient safety impact, and anticipated cost savings. From the
submissions, we developed a complete business case for three of the
recommendations and presented these to VA Under Secretary for Health Dr.
Thomas Garthwaite. He has given us an enthusiastic green light to pilot
test these recommendations in selected facilities and VISNs. Based upon
the pilot tests, we will role these out nationally.

Our congratulations to:

 Pamela Bennett, RN, MSN, Patient Safety Manager of Salt Lake City VAMC

**[Recommendation:]{.underline}** Change in humidification system for
ventilator-dependent patients

 Mary Huddleston, RN, MSHE, Patient Safety Manager for VISN 8

**[Recommendation:]{.underline}** End Cap CO2 detectors to be used on
crash carts for all codes

 Mary Watson, APN Falls Program Coordinator for Little Rock VAMC

**[Recommendation:]{.underline}** Hip pads as integral part of falls
prevention program

Additional thanks and recognition for submissions by:

 Deborah Dallimore, Risk Manager, New Orleans VAMC

 Lin Hillman, Patient Safety Nurse and Patrick Mulrain, Facility Safety
Officer, Tomah VAMC

 Linda Swan, VISN 22 Patient Safety Manager

 Gloria Williams, VISN 9 Patient Safety Manager

 Karole Wire, Quality Manager, Danville VAMC