What do you do after an accident for those that are impacted by the accident? Linda will talk at the TapRooT® Summit about her medical sentinel event and how people involved need to be supported.
Here’s a video that will provide you some background about Linda and MITSS.
While influenza outbreaks appear to be slowing, neither the WHO, nor CDC has declared an end to this pandemic. There are still some areas with widespread influenza activity.
NOVEL H1N1
In an overview of flu activity during the 2009-10 flu season that started Aug 30, the US Centers for Disease Control and Prevention (CDC) said pediatric deaths from the pandemic virus are three times higher than the average for the past three seasons. Flu activity peaked on Oct 24, much earlier than the February peaks of the most recent flu seasons. The CDC pointed out that multiple waves were seen during the three most recent pandemics, emphasizing the importance of vaccination.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5902a3.htm?s_cid=mm5902a3_x
Though older people appear to have some immunity to the pandemic virus, the US Centers for Disease Control and Prevention learned of several outbreaks at nursing homes, detailing three inMorbidity and Mortality Weekly Report (MMWR). They occurred during the fall before the vaccine was widely available, and infections in healthcare workers were documented at two of the facilities. Infection control steps and antiviral prophylaxis seemed to slow flu spread.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5903a3.htm?s_cid=mm5903a3_x
During 2009, 73 laboratory-confirmed cases of human infection with highly pathogenic avian influenza A (H5N1) virus were reported to WHO from 5 countries. The 73 laboratory-confirmed cases of H5N1 virus infection were reported from Cambodia (1 case), China (7), Egypt (39), Indonesia (21) and Viet Nam (5); all of these countries reported human cases of H5N1 previously. Circulation of highly pathogenic H5N1 virus in poultry is considered to be endemic in these countries.
With almost double the number of human cases of H5N1 reported in 2009 compared with 2008, and with continuing circulation of the virus among certain poultry populations, it is clear that H5N1 remains a concern for both animal health and public health.http://www.who.int/wer/2010/wer8507.pdf
VACCINE
Given signs that the pandemic H1N1 virus will continue its dominance over other flu strains, the World Health Organization (WHO), CDC, FDA, etc. have recommended adding the pandemic strain as the H1N1 component of the seasonal flu vaccine for the Northern Hemisphere’s next flu season. Additionally, they have also changed the other influenza A strain, replacing the Brisbane H3N2 component with a Perth H3N2 strain. The influenza B component (changed last year) remains the same.The recommendation for next season’s vaccine:
· A/California/7/2009 (H1N1)-like virus
· A/Perth/16/2009 (H3N2)-like virus
· B/Brisbane/60/2008-like virus.
The Advisory Committee on Immunization Practices (ACIP) voted to expand the recommendation for annual influenza vaccination to include all people aged 6 months and older. The expanded recommendation is to take effect in the 2010 – 2011 influenza season. The new recommendation seeks to remove barriers to influenza immunization and signals the importance of preventing influenza across the entire population. The vote took place against a backdrop of incremental increases in the numbers and groups of people recommended for influenza vaccination in years past, and lessons learned from the world’s still ongoing first flu pandemic in 40 years.
In an effort to maintain the nation’s supply of drugs and other medical products in the event of a pandemic or other emergency, the US Food and Drug Administration (FDA) recently issued guidance to help pharmaceutical companies plan for high absenteeism rates. It focuses on “medically necessary products” such as antivirals and details what the FDA could do to help protect the supply. The guidance is also aimed at companies that make the raw materials and components used in the products.http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM196497.pdf
College students living in dorms reduced their risk of influenza-like illness (ILI) at the peak of the flu season by wearing surgical masks a few hours a day and practicing good hand hygiene, say researchers from the University of Michigan. There have been many studies that point out the effectiveness of masks, hand hygiene & social distancing as very effective tools.http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/jan2210masks.html
COMMENTARY
As the H1N1 pandemic vaccine becomes available in your area, I urge you to get it – for yourself, your family & your community. In the meantime, continue to practice good hygiene and social distancing.
We discussed the use of checklists in the medical industry in a previous blog entry. Yesterday, CNN’s Sanjay Gupta interviewed Dr. Peter Provonost, a medical researcher at Johns Hopkins University. He was selected in 2008 as Time Magazine’s Top 100 Most Influential People. He had a great discussion on the use of checklists in medical industry, specifically hospitals. He mentioned a statistic that there are over 30,000 preventable deaths each year in the US due to inadvertent infections that could be mitigated by the use of simple checklists. He said that consistent use of checklists in the medical industry would save more lives than any other single medical therapy currently being developed. Quite a statement! Something as cheap and as inexpensive as implementing simple checklists could save more lives than many of the more expensive therapies now under development. What do you think? With so much research indicating the benefits of checklists, why have they not yet come into widespread use?
Because TapRooT® produces consistent results (it is structured and repeatable).
Because TapRooT® helps investigators find causes beyond their current knowledge.
Because TapRooT® helps investigators find all the root causes, rather than just the most obvious or their favorite ones.
Because TapRooT® has been tested and proven at leading companies around the world. (See Success Stories at: http://www.taproot.com/about.php.)
Because TapRooT® has patented software to make an investigator more productive.
Because TapRooT® has the Corrective Action Helper® Module to assist investigators in developing effective corrective actions.
Because management can understand the results and can approve the recommendations to improve performance.
Because TapRooT® is constantly being improved by a dedicated staff of experts that receive feedback from thousands - actually, tens of thousands - of users around the world.
Because the TapRooT® books, training, and investigation aids are so helpful.
Because TapRooT® Users are supported by newsletters and a Summit to help them continually improve their investigation skills.
That’s just a start of the reasons that TapRooT® Users are so successful and that you should be thinking about using TapRooT® if you don’t already use it.
Perhaps the NHS will look for improved root cause analysis tools (their current training, that I found outlined on-line, mentions 5-Whys and Brainstorming) and get better results that will help them improve outcomes in the UK. At least that what I thought when I read the article.
In 1935, the most experienced test pilot crashed the most advanced airplane, the Boeing 299. The papers said it was too much plane for one man to fly. As it turns out, it wasn’t “too complicated” – rather, there was just too much to remember. Too many controls to remember to set. Set something wrong (or forget to set it) and the plane would not fly. Flying had grown too complex to depend on a person’s memory.
The answer was simple: a checklist. Actually, four checklists. At first, pilots resisted. But it’s hard to argue with the evidence that checklists really helped avoid common errors and kept planes from crashing. Now, aviation checklists are a staple of the professional pilot.
I would argue that medicine became too complex to rely on doctors’ or nurses’ memories long ago. Hospitals need to adopt the best practices that are the staple of high performing organizations (for example, aviation or nuclear power). It is far past the time that standard practices and checklists should have been adopted to stop sentinel events. Especially when a twelve-year study published in the January 2009 issue of the New England Journal of Medicine shows a 40% reduction in accidental deaths when hospitals use checklists.
That’s just one of the best practices that should be adopted immediately to improve performance in the complex environment of a modern hospital. Where can you learn more? Try a TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. Then attend the TapRooT® Summit in San Antonio (October 27-29) for more best practices to improve performance. You could be part of the movement to save thousands of lives every year by applying known best practices to improve healthcare quality and patient safety.
The patient who was getting an MRI had a knife strapped to his leg (guess he wanted to be ready for anything during the MRI). The story then says…
“The knife got sucked out of its sheath and cut the patient in the abdomen, requiring stitches. Before he was taken to the MRI, the patient was screened for objects that would be attracted to the magnet. He reportedly ’stated that his pockets were empty.‘”
One of the researchers on this study, Dr. Atul Gawande, was interviewed on National Public Radio this morning (link here). He went into even more detail and and provided further insight on this study. He discussed how complicated and intricate the medical profession has become, and therefore instituted the use of checklists in the operating room in 8 hospitals. He had some amazing (but not unexpected) findings:
“We get better results,” he says. “Massively better results.
“We caught basic mistakes and some of that stupid stuff,” Gawande reports. But the study returned some surprising results: “We also found that good teamwork required certain things that we missed very frequently.”
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
How did the surgeons respond?
…when his team surveyed the doctors who used the checklist, “There was about 80 percent who thought that this was something they wanted to continue to use. But 20 percent remained strongly against it. They said, ‘This is a waste of my time, I don’t think it makes any difference.’ And then we asked them, ‘If you were to have an operation, would you want the checklist?’ 94 percent wanted the checklist.”
Checklists are a way of life in many critical, complex industries. The airline, nuclear, and pharmaceutical industries all use checklists to some extent, but many in the medical community are still resistant. We have even seen a reluctance to perform a root cause analysis for sentinel events. Many people feel that, if they are using a checklist, they are perceived as not being an expert at their job. And yet, Dr. Gawande had some amazing statistics concerning the sheer volume of information presented to physicians:
- The average physician evaluates 250 primary diseases and conditions each year - These same patients have an additional 900 additional medical problems - The doctors prescribed over 300 different medications, 100 lab tests, and performed 40 different types of office procedures - In an ICU, the average patient requires 178 individual actions per day (administering drugs, suctioning lungs, etc) - Out of those 178 actions, 2 per day (~1%) were performed incorrectly
Sometimes, memory is just not enough. When a sentinel event occurs, perform a TapRooT® analysis. See how many times “no procedure” and “no standard turnover process” show up as root causes.
“A call from a flight attendant to the pilots of the Northwest Airlines plane that overshot Minneapolis catapulted the cockpit crew from complacency to confusion.
According to a statement signed by flight attendant Barbara Logan, she called the cockpit around 8:15 p.m. CDT to find out when they would be landing. She was told they would land around 12 Greenwich Mean Time. “I said I did not know the time — he said I was hosed and hung up.”
The lead flight attendant called to get gate information and was apparently also hung up on, according to Logan’s report. That flight attendant later got through to the cockpit.”
Years ago would the Flight Attendant have pushed so hard before CRM?
Now an example where CRM would helped in the death following a scheduled surgery. An everyday medical procedure ended up in an excessive delay of needed oxygen to the patient.
Bad behavior between doctors and nurses in hospitals can cost patients their lives. So about a year ago, the Joint Commission required hospitals to create a “zero-tolerance” policy for intimidating and disruptive behavior.
Recently, the American Medical News published an article that indicates that the requirement for a policy might not be working.
After reading the article you might ask yourself the question:
“Can a policy stop bad behavior?“
And what does “zero-tolerance” mean? Any bad behavior should get a nurse fired or a doctor’s privileges suspended?
Here’s a list of the “bad behaviors” that were reported in the American College of Physician Executives 2009 Doctor-Nurse Behavior Survey and the percentage of respondents that had observed that type of behavior in the last year in their organization …
Degrading comments and insults … 84.5%
Yelling … 73.3%
Cursing … 49.4%
Inappropriate joking … 45.5%
Refusing to work with a colleague … 38.4%
Refusing to speak to a colleague … 34.3%
Trying to get someone unjustly disciplined … 32.3%
Throwing objects … 18.9%
Trying to get someone unjustly fired … 18.6%
Spreading malicious rumors … 17.1%
Sexual harassment … 13.4%
Physical assault … 2.8%
Other … 10%
Could we really have a zero-tolerance policy for yelling? For inappropriate joking?
Who would decide what inappropriate is and then enforce it across all hospitals?
I’m not saying that any bad behavior including yelling and telling inappropriate jokes is a good thing. I just don’t know if “zero-tolerance” is the way to change behavior…
I’m getting behind on my Summit reporting because of all the amazing talks and amazing discussions I’m having. I just can’t keep up.
Here are some of the highlights…
Success Stories: I attended a session with two success stories yesterday. Ron Pryor (Alcoa) and Theresa Guay (Irving Oil) presented their stories of how they were using TapRooT® to get significant improvements in environmental, quality, and safety performance. We’ll post the Success Stories at http://www.taproot.com/about.php when we get back from the Summit, so you can look for the details there. But what you can’t get from the written word is the Q&A that occurs at the session. For that, you must attend the Summit.
Personal Development: Next, I went to a great presentation by Jennifer Mounce that was very interactive. She taught us about coaching ourselves to get better and bring our personal performance to the next level. Once again, you had to be there to participate and learn. It really gave me some good ideas to act on to improve my own performance.
(E.D. signing books. Mark, E.D., & Linda just before the 70’s themed party.)
Lessons from Success: Then we had an inspiring General Session talk by E.D. Hill. Wow! E.D. is smart, insightful, and a great speaker about lessons from the success of others and her own career. After her talk she spent and hour and a half with us signing her book and talking to people one-on-one. She even came to our reception where the band Entice entertained Summit participants.
Lessons from an Accident: This morning I heard an amazing talk about an injury, the aftermath, and the investigation that changed the standard of care for electrical injuries in the province of Ontario. Jim Thompson, Brian Tink, and Dr. Joel Fish shared their story which was very impressive. We had to cut off the Q&A and let people continue the discussion at the break.
Equipment Failure Lessons Learned: I’m now in a talk about “Persistent Equipment Failures” by Ken Bloch. He’s talking about equipment failures that cause process safety incidents. One neat detail so far … He quoted a statistic that process plants could expect one fire per 1000 pump repairs.
More later.
Plant to attend the 2010 Summit so that you can learn, improve, and share best practices with some of the best companies in the world.
When will it be?
October 20-22, 2010, in San Antonio.
Planning has already started and I’ll let you know more when things are confirmed.
Read the article on the IOSH web site and you’ll find that MISTAKES (human errors) administering oxygen to patients in UK hospitals is what actually killed nine in five years.
He went in for a “routine dental cleaning and tooth extraction at a hospital in Seattle.
Things went OK. They gave him a prescription for a pain killer.
The doctor (a DDS resident) prescribed it.
The nurse checked it.
The pharmacist checked it.
The prescription was slightly unusual - a fentanyl transdermal patch. The doctor decided to use this pain reliever because the boy was autistic and could not tolerate liquid or pill form medication.
What all three people failed to notice was that this form of medication was highly potent and was only to be used by people who had already built up a tolerance to opioids. Otherwise, these drugs can kill by stopping respiration.
But the doctor, the nurse, and the pharmacist missed this.
Now it gets interesting.
The doctor performing the surgery didn’t prescribe the medicine. Instead, a resident that was assisting wrote the prescription. It isn’t clear if the doctor performing the surgery reviewed the prescription or not.
Some questions that weren’t answered by the article:
- How many hours had the resident worked? (Was fatigue an issue?)
- How did the resident pick that drug?
- How did the packaging and prescription tools warn about the care needed in prescribing and using this drug?
The corrective actions by the hospital was to add more human action safeguards around the prescription of this drug (additional reviews).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wrote it in the first paragraph.
The toll of this inadequate leadership is staggering - about 50,000 deaths per year. (Taking the estimate of deaths in the US from the Institute of Medicine report and multiplying it by 50%).
Another way to think about this is that perhaps 1/2 of the 5708 registered hospitals in the US have inadequate leadership. That’s 2604 hospitals that need to improve their leadership and probably should be concentrating on learning advanced root cause analysis and performance improvement best practices.
We’ve always sent information about the Eliminating Healthcare Sentinel Events Best Practice Track and TapRooT® Training to risk management, patient safety, and quality improvement professionals at hospitals. Maybe we should be sending the information to hospital administrator to reach the top of the leadership pyramid?
If you think your administrators need to know more about root cause analysis and preventing sentinel events, pass our newsletters along. Or sign them up to get our newsletters monthly at:
Also, pass along information about the Eliminating Healthcare Sentinel Events Best Practice Track at the TapRooT® Summit. They will be amazed at what they learn. See the schedule by clicking on the appropriate button on the left at:
“Denise Nichols, the vice president of the National Gulf War Resource Center, says the VA is blaming a coding error for the mistake.”
Where would this event be placed for investigation… the Quality Group? …… the Risk Group? Would it get a thorough Root Cause Analysis? Where would you start… with the Coding problem? … when the notifications were sent out? When the problem was caught?
The answer is all of the above! Problem is that often quality issues will not get the level of attention as would a Sentinel Event. Problem is Quality and Patient Safety are part of the same system, no matter what the title on the door.
Join us to learn, network and engage with fellow healthcare professionals and executives at the 2009 TapRooT® Summit, featuring five keynote addresses and 8 information-packed best practice sessions! Ed Skompski, Vice President of System Improvements, invites you to register for the Eliminating Hospital Sentinel Events track scheduled for October 7-9 in Nashville, Tennessee.
I don’t believe in criminalizing errors and putting people in jail for honest mistakes.
Here’s one where the supervisor (a pharmacist - Eric Cropp) pleaded guilty to involuntary manslaughter and received a six month sentence, plus six months house arrest, plus three years probation, plus 400 hours of community service, plus a $5,000 fine after a technician made a mistake in mixing a chemotherapy prescription (ended up with 23% saline rather than 1%) and killed a two year old.
“Dudash, in her statement, wrote that she told Cropp, “This doesn’t seem right,” after preparing the intravenous solution for Emily’s chemotherapy. Cropp “shrugged it off,” she wrote. Joann Predina, a pharmacy board investigator, found Dudash had spent time on the Internet “planning her wedding” during a lull before the error.
Cropp, in his own notarized statement to the board, wrote that he had been rushed, “which caused me to miss any flags that Katie had done something wrong.”
Unlike Cropp, Dudash has not faced disciplinary action or prosecution. In part, that’s because Ohio is among at least 11 states that do not regulate pharmacy technicians. In Ohio, “The technician has no legal responsibility. It all falls back on the shoulders of the pharmacist,” says Tim Benedict, assistant director of the state’s pharmacy board.
After the fatality, Dudash returned to the CVS(CVS)drugstore chain, where she had worked and passed a technician training program before landing the hospital job. CVS spokesman Michael DeAngelis says she now holds a non-pharmacy job and would not grant interviews.”
Here’s another story about the sentinel event that was published in the Cleveland Plain Dealer:
I saw this message yesterday on a patient safety related list serv and I thought it was so thought provoking that I had to pass it along.
Here’s what I read:
From: Robert Sinsheimer
Subject: Medical Safety V. Gun Safety: An email now in circulation
Doctors
(A) The number of physicians in the U.S. is 700,000.
(B) Accidental deaths (medical error) caused by physicians per year are120,000.
(C) Deaths due to medical error per physician is0.171
Statistics courtesy of U.S. Department of Health and Human Services
================
Now think about this:
Guns
(A) The number of gun owners in the U.S. is80,000,000. (Yes, that’s 80 million)
(B) The number of accidental gun deaths per year, all age groups, is 1,500.
(C) The number of accidental deaths per gun owner is.000188.
Statistics courtesy of FBI
============
So,statistically, doctors are approximately9,000times more dangerous than gun owners.
===========
Remember, ‘Guns don’t kill people, doctorsdo.’
============
FACT: NOT EVERYONE HAS A GUN, BUTALMOSTEVERYONE HAS AT LEAST ONE DOCTOR.
============
Pleasealert your friends to this alarming threat.
We must seek to impose doctor control before this gets completely out of hand!!!!!
- - -
This e-mail was obviously a tongue-in-cheek joke. But when you start seeing e-mails like this, you know that the time has come for more drastic action to improve patient safety.
What can you do at your hospital to get out in front of the pack? Attend theTapRooT® Summitand learn best practices from around the world.
“… hospital leaders say they’ve made great strides toward preventing mistakes“
“A recent analysis by Hearst Newspapers showed no progress in driving down deaths caused by hospital mistakes.“
Can they both be right?
My guess is that the exponentially accelerating complexity of modern medicine will result in MORE errors and MORE deaths despite piecemeal efforts to improve patient safety. Thus, every hospital needs to redouble their efforts to implement best practices from others in the healthcare industry and FROM OTHER INDUSTRIES if they hope to get ahead of this problem.
Where can your hospital learn these needed best practices? Start with three days at the TapRooT® Summit. See:
Healthcare reform (or insurance reform) is a big topic in the news. But perhaps the real discussion should be on medical treatment reform?
A recent article in the Albany Times-Union suggests that the death toll in the US due to medical mistakes has doubled in the past decade and is closer to 200,000 per year that the original report by the Institute of Medicine’s original 1998 estimate of 100,000 per year.
Isn’t it time that we eliminated sentinel events by applying best practices from hospitals and other industries?
The TapRooT® Summit has a track titled:
“Eliminating Hospital Sentinel Events Best Practices Track”
That will help you see ways to make major improvements in patient safety.
