Posts Tagged ‘crew resource management’

Reducing Distractions is Reducing Medication Errors – by Pat Iyer

Wednesday, August 12th, 2009

The sterile cockpit means no interruptions at critical times

The sterile cockpit means no interruptions at critical times

My father was fascinated by airplanes when I was little. I recall going to Idlewild Airport in New Jersey to watch planes land. My father was trained as an aeronautical engineer. Little did I know as a child the lessons of the airline industry would spread to healthcare and set an example for systems to reduce patient errors. Crew or Cockpit Resource Management is a term that began in 1979 as a way of defining ways to reduce pilot error through better use of the crew. The patient safety movement is now taking lessons from the airline industry. The airline industry has defined the sterile cockpit as a place which controls interruptions during critical moments of flight.

Nurses prepare medications in busy hallways of hospitals and nursing homes. It is easy to interrupt and distract a nurse during the critical steps of preparing medications. Some concerned experts in patient safety suggest the use of a vest to be worn by a nurse during medication administration. The bright orange vest says, “Do not disturb.” I first heard about the use of vest when Gary Sculli, a former pilot turned nurse, spoke to the New Jersey chapter of the American Society of Healthcare Risk Management (ASHRM). I have been an ASHRM member for many years.

Nurses at Kaiser South San Francisco Medical Center ordered bright orange, construction-style vests off the Internet, which the nurses thought looked “cheesy.” They also found them hot and resisted sharing them with fellow nurses. “They felt it was demeaning,” said Becky Richards, RN, BSN, MA, adult clinical services director Richards. But of even greater concern, despite education about not interrupting nurses during med passes, the vests seemed to attract attention. The hospital tried again on a renal floor, with separate medication rooms. But again, it just didn’t seem to click. “We were really thinking about abandoning the whole idea, because the nurses did not like it,” Richards said. But when the medication administration data came in at the end of the year, the hospital found that during the four and five months after the pilot finished, those two units combined had a 47 percent decrease in errors. The units had not done anything else to reduce errors, just the education about no distractions and the vests.

“At that point we knew we could not turn our backs on our patients,” Richards said. The quality forum nurses tweaked the program, finding more attractive neon yellow vests and reaching out to the medical staff, housekeeping and other departments for support. Kaiser South San Francisco kicked off the new program hospital-wide in April 2007, with the exception of oncology, which refused to participate, writing letters and signing a petition. The hospital decided not to play hardball.

“We were blown away in May. The hospital experienced a 20 percent decrease in medication errors, even though one unit refused to participate,” Richards said. “And that was the only unit that experienced an increase from their previous month’s error rate.”
Source: Decreasing Disruptions Reduces Medication Errors – NurseZone

This report verifies the importance of creating a safer environment for preparing medications. Controlling interruptions and eliminating distractions saves lives.

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Posted in Medical malpractice, Medication errors, Nursing malpractice, Patient safety | 1 Comment »

On Challenging an Authority by Pat Iyer

Monday, July 13th, 2009
Challenges to authority save lives

Challenges to authority save lives

A nurse sees a physician about to commit a grievous error. A resident watches an attending physician brush aside warning signs of a medical error. What factors go into challenges that may save a patient’s life? Malcolm Gladwell provides insights in Outliers. The author of The Tipping Point and Blink, Gladwell’s engaging writing is a delight. Here’s what I gained on this subject.

The concept of power distance is concerned with attitudes toward hierarchy, specifically with how much a particular culture (or group of professionals within that culture) value and respect authority. There are low-power distance index countries, like the United States, and high power index countries, like the Philippines. Here’s what we see in nursing: a nurse can be ignored or chastised if she challenges a physician from a male-dominated society where women are considered to be less than equal. On the other hand, a nurse from a society that puts physicians on a pedestal may be unable to challenge the decision making when needed.

How does this apply to patient safety and medical malpractice? And how can healthcare providers prevent those lost or ruined lives that result from medical disasters? How do we avert medical and nursing malpractice if those who speak up are ignored?

1. First, healthcare staff should be given the skills and the words to use to question authority. One of my job responsibilities in 1987 was to teach assertiveness skills to Filipino nurses. I recall the startled expressions on their faces when they realized they were expected to challenge physicians. This was not part of their training at the time. The healthcare culture must actively and visibly support the need to speak up. This is an incredibly threatening concept for those stuck in the high power distance mindset.

2. We can learn from the airline industry. Crew Resource Management concepts are being adopted by healthcare institutions. For example, according to Gladwell, many airlines teach a standardized procedure for copilots to challenge the pilot if he or she thinks something has gone terribly awry. They may say, “Captain, I’m concerned about…”then, “Captain, I’m uncomfortable with…” and if the captain still does not respond, “Captain, I believe the situation is unsafe.” And if that fails, the first officer is required to take over the airplane. Imagine nurses, residents, or others being taught how to telegraph their concerns in such a fashion. Nurses are taught to contact their nursing supervisor if a challenge to a physician is ignored.

3. I think there is another factor at work, which Gladwell refers to as “practical intelligence”. This includes things like knowing what to say to whom, knowing when to say it, and knowing how to say it for maximum effect. It is knowledge that enables you to read the situation correctly and get what you want. A person with high practical intelligence would know how to challenge another person’s actions or decision making in a way that would bring results. The nursing supervisor should embody these skills.

4. Keep in mind that healthcare medical disasters can happen just as quickly as a plane can plunge into the ocean. A bleeding vessel in the operating room, the incorrect administration of intravenous chemotherapy into spinal fluid, the fetus that shows signs of needing to be delivered right now- all constitute emergencies. The person with low power distance, communication skills and practical intelligence is in the best position to save patient lives.

5. Patient safety application:
The person who is a silent witness to the disaster, who is afraid to speak up and be a patient advocate, and the person who ignores those who question decision making may end up as part of the chain of a medical disaster.

6. Business application:
If you work within a law firm or legal nurse consulting firm, actively encourage your staff to speak up, to question, to point out problems. Listen to their concerns. You might be functioning with blinders on and not able to see an emerging situation. Thank those who are watching over your shoulder and serving as your safety net.

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