# NCPS TIPS -- May/June 2002

### Contents: 1. PSRS Roll Out Completed

> 2\. Total Care Bed System Notice
>
> 3\. CPRS Patch Training Need
>
> 4\. HFMEA^TM^ Golden Nuggets

5.  Facility Feedback

6.  Safety Spotlight

7.  Spring is a Good Time to Review Elopement Risks

### 

### 1. PSRS ROLL OUT COMPLETED

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

VA and the National Aeronautics and Space Administration (NASA) have now
rolled out the new Patient Safety Reporting System (PSRS) throughout all
VA's hospitals. Developed in a partnership with NASA, PSRS is an
independent and external reporting system that is complementary to VA's
internal reporting system.

All facilities received PSRS display holders during the month of May
that contained reporting forms and brochures; these are being posted
throughout all VA hospitals. Facilities will also be receiving PSRS
posters, a CD containing automated PowerPoint presentations on PSRS, and
a ten-minute introductory videotape on PSRS. These materials were
produced to help educate VA employees about PSRS.

The guiding principles of PSRS are voluntary participation,
confidentiality of information submitted, and non-punitive reporting.
"When individuals feel uncomfortable reporting to the internal systems,
they have a safety valve they can use -- PSRS," stated Dr. James Bagian,
Director of the VA National Center for Patient Safety. All a reporter
needs to do is fill out the pre-addressed and postage-paid PSRS form and
drop it in any mailbox. Reports submitted to PSRS are confidential and
privileged quality assurance documents protected under the provisions of
38 USC 5705.

Currently, 100 VA facilities have received endorsements from their labor
unions for PSRS. For facilities that have not received union
endorsement, the program is still available for all non-union employees.

Please note that PSRS is designed to identify system vulnerabilities,
but not to provide detailed solutions for local facility adverse events
and close calls. For more information about PSRS, please contact your
facility Patient Safety Manager or PSRS directly at NASA/PSRS, P.O. Box
4, Moffet Field, CA 94035-9958 or visit their website at
psrs.arc.nasa.gov.

### 2. Total Care Bed System Notice

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

On January 30, 2002, Hill-Rom issued a notice to 43 VA facilities that
had purchased their Total Care Bed System beds between November 1, 1997
and October 5, 2001. In this notice Hill-Rom identifies two potential
failure modes associated with the Total Care Bed System bedside rails.
The first involves unintentional up or down movement of the bed during
cleaning if fluids enter the side rail and short circuit electrical
components. The second failure mode may result in the bed not operating
due to flexing of the P.C. board after repeated operation of the bed
assembly.

As of May 13, 2002, all VA facilities known to have these beds have been
contacted; a list of these VA facilities is posted on the NCPS intranet
site (http//vaww.ncps.med.va.gov) along with a copy of the notice from
Hill-Rom. If you have this equipment and have not taken corrective
action please follow the instructions in this notice.

### 3. CPRS PATCH TRAINING NEED

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

In April 2002 a new national patch (EAS\*1\*3) was released for the
VistA Enrollment Application Systems (EAS) software. This enhancement
generates letters to veterans at designated times prior to the
expiration of their means test and prevents the scheduling of future
appointments for patients without a current means test.

Concern was expressed by a Patient Safety Manager that a patient's
immediate follow-up care could be delayed due to an expired means test.
The delay could result from the inability to immediately schedule a
follow-up appointment due to expired means test data. Selected
individuals at the medical center, generally supervisory personnel, hold
an EAS MTOVERRIDE security key that allows overriding this appointment
block if required due to extraordinary circumstances. Individuals at
your facility responsible for scheduling appointments should receive
training and know the identity of the supervisory staff capable of
overriding this blocking function. For additional information on
training materials visit the Enrollment Training Initiative web page at
vaww.vistau.med.va.gov/enrollment/default.htm. We also recommend that a
cognitive aid identifying individuals holding the security key be
developed and made available to assist staff.

### 4. HFMEA^TM^ GOLDEN NUGGETS

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

The following tips or "golden nuggets" have been put together from
lessons learned during Healthcare Failure Mode Effect Analysis (HFMEATM)
training sessions and by reviewing early HFMEATM reports. NCPS believes
conducting a proactive risk assessment is a worthwhile exercise and
expenditure of staff time. NCPS has reviewed several RCAs on the
problems surrounding timely administration of medications when
facilities have lost their BCMA capacity. When they had to actually
implement their contingency plan, facilities found that their plans were
inadequate and had not considered all failures. A thorough HFMEATM can
avoid these shortcomings.

• Think of failure **modes** as "what could go wrong" that would prevent
the process or sub process step from being successfully completed.

• Think of the failure mode **cause** as "why" the failure mode would
occur.

• Present failure modes as a problem statement that needs to be
corrected (e.g., inadequate printer power supply vs. utility failure.)

• When doing the process flow diagram ensure the team is diagramming the
process steps that **actually occur and not the ideal process**.

• After the team develops the process diagram, have some team members
visit the work area to observe staff performing the process to verify
that their assumptions are correct.

• Follow the numbering and lettering format for the process and sub
process diagrams. This is essential to keep the team organized when they
move on to identifying failure modes!

• The goal of the performance measure is ensuring the timely
administration of medication in the event of partial or complete failure
of BCMA; make sure that your HFMEATM addresses the vulnerabilities of
your BCMA contingency plan.

• Chronological event flow diagrams used in RCAs are different from
process flow diagrams used in HFMEATM. Event diagrams are specific to
what actually happened on the day of the event. Process diagrams depict
the usual activities needed to complete the task(s).

• In order for a failure mode or failure mode cause to be classified as
"detectable" on the HFMEATM Decision Tree, it must be so visible and
obvious that it will be discovered **BEFORE** it interferes with
completion of the task or activity.

• As required on Table 19 for RCA reports, a single individual should be
identified as being responsible for follow up on the corrective actions
identified on the HFMEATM Worksheet.

• Use the most current version of the HFMEATM Worksheet, visit
vaww.ncps.med.va.gov if you are unsure. The Worksheet was significantly
modified from the one used during the original roll out of the program
in August of 2001.

• Some medical centers have found it effective to have more than a
single representative from key disciplines on the team. This increases
the chance that necessary disciplines will be represented at all
meetings and that work can be completed in a timely fashion.

• Remember to conduct the hazard analysis on the failure mode before
identifying failure mode causes. This will prevent you wasting time
identifying and assessing causes that don't need to be addressed. Use
the arrow on the Worksheet as your cognitive aid!

• Check the NCPS intranet (http://vaww.ncps.med.va.gov) or internet
([www.patientsafety.gov]{.underline}) as we periodically update the
HFMEATM training materials.

### 5. 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.)

# TIPS Tips

We have come up with some great ideas for improving distribution of TIPS
in our facility. We've added a question sheet that says "List three
things you learned from reading this issue of TIPS" and put TIPS on the
staff education page of our intranet site. We've also added TIPS, along
with the questionnaire, to our monthly newsletter. Our staff sends a
copy of the questions to me, the patient safety officer, and a copy to
their TEMPO person to earn patient safety training credits by reading
TIPS.

**\-- Judith O'Neal**

**Reno VAMC**

# Patient Safety Awareness Week

The nation's first Patient Safety Awareness Week was celebrated March
10-16, 2002. Northport VAMC staff, along with a host of other VA medical
centers, held activities to celebrate this event.

Patient Safety Awareness Week activities at Northport included a Patient
Safety Health Fair highlighting VA and local safety projects, and a
Safety Forum featuring a panel discussion on error disclosure.

Patient Safety Awareness Week was the idea of Ilene Corina, the founder
and director of Persons United Limiting Substandards and Error in Health
Care (PULSE) of New York, a national group devoted to improving patient
safety. The State of New York issued a proclamation establishing Patient
Safety Awareness Week, and the Week was also endorsed by the VA National
Center for Patient Safety and the National Patient Safety Foundation.

Don't forget to set aside the date for the next Patient Safety Awareness
Week \-- March 9-15, 2003. We are already beginning plans on our
activities for next year's event.

**\-- Mark Graber, M.D.**

**Northport VAMC**

*(**NCPS Note:** Planning any special activities for next year's Patient
Safety Awareness Week? Please drop us a line at ncpstips@med.va.gov so
we can highlight in future issues of TIPS how facilities will be
celebrating this event.)*

### 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 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.)

# Wrong Code Team Called

####### Description

A patient who had recently had a knee replacement arrived for a
scheduled rehabilitation session in Physical Therapy, which is located
on the fourth floor of Bldg. D. Shortly after the session began the
patient started complaining of shortness of breath. The patient then
started feeling hot and started vomiting. The resident physician on call
was summoned and requested that oxygen be administered, but the patient
continued to deteriorate. The patient arrested and CPR was administered
by ACLS protocol. At the same time, a call was placed to the VA police
stating there was a code in Physical Therapy. For code calls, all areas
of Bldg. D are covered by the community ambulance except for Physical
Therapy, which is covered by the code team. The police officer hearing
the request, who was trained in arrest team procedure but was new and
had no previous experience in handling code calls, called the community
ambulance team instead of the hospital code team. During this time,
there was difficulty with completely inflating the reservoir of the
manual resuscitation bag with oxygen because the regulator did not go
past 8 liters per minute. Use of an oxygen tank with a flowmeter that
delivered 15 liters per minute of oxygen solved this problem.

The community ambulance EMTs arrived on the scene and assisted, but the
staff at the scene still requested that the hospital code team be
called. It was decided to continue CPR and transport the patient to the
Cardiac Care Unit on the fifth floor. The hospital code team met the
patient while in transport to CCU. The operator of the surgical elevator
was called but did not respond, so the patient was taken on the freight
elevator. The freight elevator malfunctioned, going up a few floors, and
then descended back down to the fourth floor. The team and patient got
off on the fourth floor and found the surgical elevator operator who
took the group and patient to the fifth floor CCU. The patient went into
cardiac standstill shortly upon arrival in CCU and expired.

####### Identified Vulnerabilities

The following vulnerabilities and systems weaknesses are identified:

The procedure for responding to codes in Bldg. D, along with VA police
experience in notifying code teams, with the stress of a real emergency
situation, led to the wrong code team being called.

The flow rate on the oxygen regulator was not sufficient to inflate the
reservoir on the manual resuscitation bag.

The delay in locating the surgical elevator operator in conjunction with
the malfunctioning freight elevator caused a critical delay in the
patient arriving at the CCU.

####### Actions Taken

In response to this case, the following actions were taken:

A senior officer will always be assigned to the police station desk and
Physical Therapy will place a test call quarterly to the police desk to
check what code team the police would call.

Crash carts will only have "Thorpe" regulators that can deliver more
than 15 liters per minute of oxygen for use with the manual
resuscitation bags.

A second surgical elevator operator will be added to each shift and a
new elevator repair contract will be initiated.

#### NCPS Comments

*The RCA team might have also considered:*

*Conducting drills with each police officer on summoning code teams to
Bldg. D.*

*Integrating code team response in Bldg. D by simplifying the process so
that the internal team responds to all areas of the building would
eliminate the vulnerability.*

*Eliminating the need for a surgical elevator operator by updating
equipment.*

*In summary, we would emphasize the importance of routine end-to-end
tests and drills to make sure that published procedures and policies
dealing with high risk events can be and are actually carried out as
planned.*

### 7. Spring is a Good Time to Review Elopement Risks

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

In most parts of the country we are now welcoming spring. The leaves are
on the trees and lilacs and tulips dot the landscape. People long to be
outside enjoying the fresh air and feeling the warmth of the sun on
their shoulders. This long awaited desire to be outdoors brings with it
a heightened concern of patient elopements.

Patients are taken onto porches, into courtyards, and down walkways
where they tour the grounds with volunteers and staff. But when patients
are out of their familiar surroundings the stimulus of a different
environment has the potential to create distractions for everyone. In
the interest of patient safety, this is a good time to review the topic
of missing patients and patient elopements.

Last year all VA hospitals received copies of the VHA Escape And
Elopement Management flipbook, a tool to assist facilities in conducting
elopement risk assessments. This book is helpful for risk assessments
and identifying specific at-risk patient behaviors. It also provides
corresponding activities and environmental enhancements that may
mitigate escape elopement risk. To request additional copies of the
flipbook, e-mail NCPScognitiveaids@med.va.gov.

#######