+1 862 207 3288 Topic: Questions to participants in a semi-structured interview
Order Description
Research question: what factors compromise patient safety for adults undergoing hemodialysis from the nursing perspective in HD unit in Saudi?
Aim of the study:
To explore the perceptions of nursing staffs towards patient safety for adults undergoing hemodialysis in HD unit in Saudi.
To understand what compromises patient safety for adults undergoing hemodialysis from the nursing perspective in HD unit in Saudi.
– I need 20 question to ask haemodialysis nurses regarding their beliefs, attitude and experience toward factors compromising patient safety.
factors compromise patient safety as below:
1- medication
2-communication
3- patient fall
4- failure to follow policies and protocols
5-ability of nurses to detect errors
6-machine errors
7-infection(hand hygiene- machine-access av fistual-prevention)
8-hypovolemia(hypotension-catheter leakage-access infiltration).
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 41
Error Recovery by Dialysis Technicians
M
edical errors are a major
problem in healthcare deliv-ery. Over a decade ago, the
Institute of Medicine (IOM)
(2000) estimated medical error-relat-ed deaths exceed the combined num-ber of deaths in America attributed to
motor vehicle accidents, breast can-cer, and AIDS, and estimated that the
non-fatal morbidity from medical
errors injures a million patients annu-ally. The complexity of healthcare
practice has been proposed as one of
the major barriers to taming this
problem (Amalberti, Auroy, Berwick,
& Barach, 2005; Leape & Berwick,
2005). The complex nature of detect-ing and recovering from errors in
health care poses challenges for
healthcare professionals.
William E. Wilkinson
Lee A. Cauble
Vimla L. Patel
Continuing Nursing
Education
William E. Wilkinson, DrPH, JD, RN, CNN,
is Risk Manager, DCI Arizona, Tucson, AZ, and
Researcher, Arizona State University, Department
of Biomedical Informatics at Mayo Clinic Campus,
Scottsdale, AZ. The author may be contacted direct-ly via e-mail at wwilkinsonaz@gmail.com
Lee A. Cauble, BSN, RN, is Nurse Manager,
DCI Desert Dialysis Center, Tucson, AZ.
Vimla L. Patel, PhD, DSc, is Senior Research
Scientist and Director, Center for Cognitive Studies
in Medicine and Public Health, The New York
Academy of Medicine, New York, NY.
Acknowledgment: This research was supported by
an award from the James S. McDonnell
Foundation (JSMF 220020152) to Vimla L.
Patel. Special thanks to Lawrence Brauer, Amy
Sussman, Machaiah Madhrira, Howard Lien,
Janet Umstead-Tobias, Julie Lightner, Bradford
Guidry, Laura Davis, Rachel Buck, Stephen
Mistler and Diana Petitti at various stages in this
study.
Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-tion to this continuing nursing education activity.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 51.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Wilkinson, W.E., Cauble, L.A., & Patel, V.L. (2014). Error recovery by dialysis techni-cians. Nephrology Nursing Journal, 41(1), 41-50. Retrieved from http://www.pro
libraries.com/anna/?select=session&sessionID=2968
Experts are believed to make fewer errors than novices. Researchers in other domains
have shown that experts not only make less errors, they also detect and recover from these
errors better than non-experts. To investigate this phenomenon among dialysis techni-cians working in hemodialysis, we evaluated the ability of dialysis technicians to detect
and recover from healthcare errors. Two clinical cases with embedded errors were creat-ed by an expert nephrology nurse. Twenty-four dialysis technician subjects read the cases
aloud and then answered a set of related questions. Subjects’ error detection and recov-ery responses were scored against the clinical cases. We found that there was no signifi-cant difference between the ability of expert and non-expert dialysis technicians to detect
errors. However, expert dialysis technicians recovered from significantly more healthcare
errors than less experienced, non-expert dialysis technicians. This has implications for
training dialysis technicians in better error detection and recovery strategies.
Key Words: Patient safety, hemodialysis, dialysis technician, medication errors,
quality improvement.
Goal
To study the detection and recovery of healthcare errors of dialysis technicians as a method
to improve patient safety.
Objectives
1. Discuss the concept of error recovery and its role in patient safety.
2. Discuss the ability of expert and non-expert hemodialysis technicians to detect and
recover from errors based on the results of this study.
3. Utilize this research to improve future technician education and continuing education
programs.
Hemodialysis is a complex spe-cialty area that requires focused train-ing and experience. Dialysis techni-cians provide direct care services to
patients with end stage renal disease
(ESRD) and are cost-effective, nursing
care extenders under direct nursing
supervision. Dialysis technicians are
required to learn specialty skills and
undergo extensive on-the-job training
because during treatment, patients can
suffer severe fluid and electrolyte im -balances, or can develop cardiac, pul-monary, and other fatal complica-tions. Dialysis technicians provide ad -ditional personnel required nationally
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 42
Error Recovery by Dialysis Technicians
to meet dialysis treatment de mands
and reduce costs (Fields, 2010; Kirby
& Garfink, 1991; Wolfe, 2011). There
are more dialysis technicians than
nurses and doctors combined who
work in hemodialysis (Medical Edu -cation Institute, Inc., 2012).
Certification is required to work
beyond 18 months in the field
(Centers for Medicare and Medicaid
Services [CMS], 2008). Arizona pass -ed legislation requiring technicians to
be certified within two years of em -ployment. As of October 14, 2008, all
Arizona patient care technicians
(PCTs) are required to become certi-fied within 18 months of employment
as a PCT (Arizona State Legis lature,
2008; Levy, 2008). Not all certifica-tion examinations approv ed by states
are nationally recognized, and certifi-cation may only be valid within the
state in which it is administered.
Prior to 2008, training of PCTs
varied from facility to facility, and
even sometimes within large organi-zations lacked standardization. Under
the 2008 CMS Conditions for Parti -cipation, V694 specifies the training
curriculum that must be included for
all PCTs (CMS, 2008). The training
program must include the following
subjects: principles of dialysis; care of
patients with kidney failure, including
interpersonal skills; dialysis proce-dures and documentation, including
initiation, proper cannulation tech-niques, monitoring, and termination
of dialysis; possible complications of
dialysis; water treatment and dialy -sate preparation; infection control;
safety; and dialyzer reprocessing, if
applicable. These eight areas have
been the foundation of the training
for all PCTs at DCI Desert Dialysis
since 1985. In addition to the didactic
portion of the training, PCTs undergo
a preceptor-led 8 to 12 weeks of clini-cal training. The preceptors are PCTs
with two or more years of experience
supervised by the nurse educator.
They have received training in adult
learning and demonstrated a willing-ness and ability to be leaders in the
clinic. Since 2003, the preceptors
have also been required to be certi-fied by a national certification pro-gram. The Certified Clinical Hemo -dialysis Technician (CCHT) adminis-tered by the Nephrology Nursing
Certification Commission (NNCC) is
the examination all have chosen at
this facility.
Though many, but not all, dialysis
technicians have substantial training,
accidental deaths of patients on
hemodialysis have occurred from dial-ysis care errors made by dialysis tech-nicians. In 2008, a 71-year-old female
patient on hemodialysis died because
a reused dialyzer still filled with steri-lant was connected to the patient with-out first rinsing out the sterilant; car-diac arrest and brain in jury occurred
(Moore, 2008). In 2005, a dialysis tech-nician did not properly tape a female
patient’s fistula access needle, which
was then covered up with a blanket.
Blood pooled underneath the patient,
and she exsanguinated (Fields, 2010).
In 1988, a 68-year-old patient on
hemodialysis died because a dialysis
technician in a New Jersey clinic gave
the patient lidocaine, an anesthetic,
instead of mannitol, used to increase
blood pressure (Palley, 1988).
Data collected by the Pennsylvania
Patient Safety Authority, a state
healthcare injury tracking system that
includes hemodialysis-related data,
illustrates the kind and frequency of
errors that occur in the care of
patients on hemodialysis. One recent
report by the Pennsylvania Patient
Safety Authority (2010) presented an
analysis of dialysis errors found in
Pennsylvania over a one-year period:
From November 1, 2008, through
October 31, 2009, Pennsylvania
healthcare facilities submitted 526
event reports involving hemodialysis
administration to the Pennsylvania
Patient Safety Authority. Medication
errors were the most common type
event submitted, representing almost
29% (n = 150) of all hemodialysis-related events. Other hemodialysis
administration events involved failure
to follow policy or protocol, such as
treatment set-up procedures (12.9%),
needle disconnection and needle infil-tration (6.1% for each category), and
falls (5.9%) (p. 87).
Preventing and mitigating care-giving errors to promote the safety of
patients on dialysis is a vital and inte-gral component of nephrology nurs-ing practice (Ulrich, 2004, 2007,
2008). “Without a doubt, our role as
patient advocates calls on us to do our
best to ensure patient safety” (Ulrich,
2008, p. 237). The few studies that
have looked at clinician error in
health care have generally focused on
physicians and not on front-line pro -viders, such as nurses, healthcare
aides, dialysis technicians, or medical
assistants (Rothschild et al., 2006).
Statement of the Problem
And Theoretical Framework
Dialysis technicians are the larg -est single category of hemodialysis
healthcare providers in the industry.
The large number of dialysis techni-cians substantiates the need to study
those healthcare errors related to
hemodialysis, which could be attrib-utable to dialysis technicians, to im -prove patient safety. The literature
shows that 10 years of experience is
required to establish competence to
become an expert (Leprohon & Patel,
1995; Patel & Kaufman, 2006;
Wilkinson, Cauble, & Patel, 2011).
Experts are believed to make fewer
errors than non-experts, yet current
research suggests experts still make
countless errors (Amalberti, 2001;
Patel & Cohen, 2008; Patel et al.,
2010; Reason, 2004). Experts have
also been found to detect and recover
from these errors better than non-experts (Nyssen & Blavier, 2006).
Experts make errors, but surpass non-experts theoretically with superior
error management strategies that help
them detect and recover from them
more effectively (Amalberti et al., 2005;
Armitage, 2009; Patel & Cohen, 2008;
Rasmussen, 2003; Reason, 1990).
Patel and Cohen (2008) outlined
three conceptual stages to describe
error recovery: near miss , miss, and
adverse event due to an error in evolution.
A near miss happens when the regular
routine is violated, but the error con-dition can be terminated prior to the
happening of unintended conse-
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 43
quences. For example, a dialysis tech-nician draws up a heparin loading
dose of 2000 units of 1000 units/mL
concentration heparin and discovers
before the heparin is given to the
patient that the heparin loading dose
should be 4000 units of 1000 units/
mL concentration heparin. The dialy-sis technician then redraws 4000 units
of the heparin to administer to the
patient who then receives the correct
loading dose of heparin (Patel &
Cohen, 2008; Patel et al., 2010). A
miss occurs when the erroneous
action is completed for an error to
potentially create an adverse outcome
yet none has happened. An example
of a miss category of error in evolu-tion occurs when a dialysis technician
connects a patient to a 2K dialysate
and discovers immediately after the
patient is connected to the dialysis
machine but before the patient is dia-lyzed that the order is for a 4K
dialysate. The dialysis technician then
disconnects the 2K dialysate and
reconnects the dialysis machine to a
4K dialysate so the pa tient is not dia-lyzed with the wrong potassium con-centration dialysate for the dialysis
time duration ordered (Patel &
Cohen, 2008; Patel et al., 2010). An
adverse event due to error in evolution
happens when an unwanted conse-quence occurs. For example, an
adverse event occurs when a patient’s
fistula access lines are reversed, the
treatment is completed, and the
patient’s blood is re-circulated so the
patient needs to be re-dialyzed. If an
error in evolution is detected and
recovered at the near-miss stage, it
can be stopped from developing into
an adverse event.
People generate mental schemata
in the error recovery process. Sche -mata are mental tools that assist indi-viduals to cognitively manage situa-tions, events, and action sequences.
The reader is referred to Ericsson and
Simon (1980) and to Patel et al. (2008)
for additional information on the con-cept of schemata and the use of sche -mata in error recovery. Schemata
help filter out irrelevant information,
leaving the relevant information to be
useful for enhancing the effectiveness
and efficiency of an individual’s deci-sion-making process. Dialysis techni-cians form their internal schemata
from their own education, training,
and past experiences regarding com-plex dialysis treatment to provide the
care they give to their patients
(Leprohon & Patel, 1995). Dialysis
technicians use their internal schema-ta to prioritize and manage errors
they are able to detect and then re -cover (Armitage, 2009; Janicik &
Larrick, 2005; Patel et al., 2010).
The purpose of this study was to
explore the ability of dialysis techni-cians to detect and recover from
healthcare errors covertly embedded
in dialysis-specific clinical care scenar-ios. We hypothesized that expert dialy-sis technician subjects (defined in this
study as those certified dialysis techni-cians with 10 or more years of dialysis
experience) would detect and recover
from more errors than the lesser expe-rienced, non-expert dialysis technician
subjects (defined in this study as those
with less than 10 years of dialysis expe-rience – whether certified as dialysis
technicians or not) as found in other
technical and professional fields. This
study was part of a larger study that
looked at the performance on error
detection and correction by nurses and
dialysis technicians (Wilkinson et al.,
2011). One part of this study with nurs-es showed performance with procedu-rally based error detection and recov-ery was significantly higher as a func-tion of expertise (p < 0.05). More
experienc ed nurses performed better
than the less-experienced nurses when
detecting and recovering procedurally
bas ed errors. However, no differences
were found between these groups for
knowledge-based errors (Wilkinson et
al., 2011).
Study Design and Methods
We conducted an empirical study
to determine if dialysis technicians
were able to detect and recover from
the number of embedded errors with-in two clinical case scenarios. The
clinical sites at which the study
occurred were part of a single nation-al dialysis care corporation. All dialy-sis technicians from five clinical dialy-sis settings in Southern Arizona were
invited to participate in the investiga-tion from June through August 2009.
Human subjects’ approval was ob -tained to conduct the research. Four
of the clinical locations were outpa-tient dialysis clinics, and one site was
an inpatient hospital setting. The five
sites were supervised by a single
administrator, and the staff rotated
working in other sites occasionally to
meet patient coverage and staff vaca-tion needs. The training of dialysis
technicians at the study locations was
overseen by one in-house masters-prepared nurse educator with three
de cades of nephrology nursing expe-rience. Dialysis technician training
included instruction with a core cur-riculum established by the national
dialysis corporation’s education de -partment and a concurrent 8 to 12-week, preceptor-led, on-the-job train-ing and evaluation component.
Clinical Case Scenarios
The clinical case scenarios were
developed under the direction of an
expert nephrology nurse who has
worked in hemodialysis for 34 years
and who was a nurse manager for one
of the chronic-care hemodialysis clin-ics in Southern Arizona. The two clin-ical scenarios reflected a composite of
realistic chronic care for patients on
hemodialysis and treatment events
that have happened or could happen
with any patient who receives hemo -dialysis treatments. Two other neph -rology nurses experienced in hemo -dialysis reviewed and validated the
clinical scenarios. The clinical cases
with the embedded errors in bold are
shown in Tables 1 and 2.
Clinical Case 1: Error
Detection and Recovery
There were five procedural er -rors. Procedural errors are defined as
errors made while performing dialysis
care that are derived from routine
schema-driven and protocol-driven
activities that are typically performed
by dialysis technicians. Procedural
errors incorporate both categories
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 44
Error Recovery by Dialysis Technicians
described in the human error litera-ture as rule-based errors (managed by
rules and procedures that may be
wrong or recalled inaccurately) and
skill-based errors (using mental mod-els of tasks automatically) (Leprohon
& Patel, 1995; Patel et al., 2010).
There were also knowledge-based
errors embedded within the two
cases. The knowledge-based error
information category required dialy-sis-specific nursing domain knowl-edge that would not be possessed by
non-licensed nursing trained person-nel. Consequently, though present in
the study cases, the knowledge-based
healthcare errors in the two clinical
cases, which were used additionally to
study nurses working in dialysis in
another study, were ignored for the
dialysis technician research compo-nent presented herein (Wilkinson et
al., 2011).
Three procedural errors involved
programming incorrect computer set-tings on the dialysis machine. Proce -dural Error 4, an incorrect potassium
concentration, was the most critical to
miss. Failure to detect and correct the
other errors could cause problems;
however, they were not necessarily
life-threatening.
Procedural Error 1: Using the
wrong dialysate. The first machine
programming error shows the time
listed in Clinical Case 1 to be 3.5
hours. The setting programmed into
the machine, which should be 3.5
hours as prescribed, is actually 3
hours and 50 minutes. This gives the
patient an extra 20 minutes of treat-ment instead of the 3.5 hours as pre-scribed. The 3.5 hours was translated
into 3 hours and 50 minutes. The pro-gramming for Procedural Error 1, the
time being extended by 20 minutes
from 3 hours and 30 minutes to 3
hours and 50 minutes, would not be
harmful to the patient under most cir-cumstances. If the amount of fluid
removed during the treatment was
increased during the extra 20 min-utes, a fragile patient could be affect-ed negatively either during the treat-ment or later at home after the treat-ment. The extra fluid loss could trig-ger electrolyte imbalance and pro-Table 1
Case 1 Text with Embedded Clinical Errors Bolded
Julia, a 61-year-old Hispanic woman, presents in triage with a two-year history
of ESRD, secondary to diabetes mellitus type II. She has a left UA fistula. There is a
thrill and bruit present per palpation and auscultation. Her vital signs are elevated with
blood pressure of 174/102, pulse 96, respirations 20. Her temperature is 96.7. She
complains of SOB and ankle swelling. Her EDW is 49.4 kg. The patient’s weight today
is 56.1 kg. Breath sounds are diminished bilaterally. She has 3+ edema in BLE. A sys-tolic murmur is audible. Julia is taken back to station 5 for hemodialysis (HD) after
being triaged. Her dialyzer is checked for her name. The dialysate bath is 4K, 2.5
Ca. Louise is assigned as her dialysis technician. The dialysis machine is pro-grammed to remove 4.2 kg of fluid over 3.5 hours of HD treatment. The red and
blue lines are both plugged into the wall outlets.Louise entered the following
machine settings: Flowrate 600, time 3:50, volume 42, heparin stop time 45 min.,
heparin rate 1500. Dialysis needles are inserted into the fistula with the red line above
and blue line below. Two hours into treatment, Julia has received the following med-ications: Epogen
®
4900 units, IV; Venofer
®
100 mg, IV; Zemplar
®
5 mcg; and
Calcitriol
®
3 mcg . Julia’s blood pressure has dropped to 96/48, and she is shouting
that both of her feet and legs are cramping. The patient is placed in minimum and
given 100 cc of normal saline IV. She improves immediately, and cramping abates for
over an hour . She then again complains of severe cramping, and 10 ml of 23.4%
saline is given IV.Julia completes her HD treatment, clamps are used to help her
blood clot, and she is instructed to return for her next treatment in two days.
Source: Wilkinson et al., 2011. Reprinted with permission from the Journal of Patient
Safety .
Table 2
Case 2 Text with Embedded Clinical Errors Bolded
Mason, a 53-year-old African-American male, came in for his usual tri-weekly
treatment. He has been on hemodialysis (HD) for two hours and 45 minutes of his
4.25 hours HD treatment run. Norma, Mason’s HD technician, shouts out, “I need
help over here now.” The charge nurse just left on break. The staff nurse notes
that Mason had 4.12 liters of fluid removed so far. The time is 10:46 a.m. The
patient is completely non-responsive to verbal questioning. The nurse notices
that the pupil in one eye is larger than the other. Attempts to arouse Mason by
shaking his shoulder are unsuccessful. A hypertonic is given via his catheter
access site.
Mason’s blood pressure is 222/134, and his heart rate is 92 and irregular.
It is Saturday and no other nurse is in the office. The charge nurse is across the
street in the kitchen on a late break because it has been a busy, hectic morning. The
nurse comes back to check on how Mason is responding to the hypertonic solution
given to him 13 minutes ago. The time is now 11:15 a.m. Mason’s condition has
not changed. He remains non-responsive, and his body is flaccid. The staff
nurse leaves Mason to get the AED. On the way to get the AED, the charge
nurse returns from break and the staff nurse tells the charge nurse what has
happened. The charge nurse calls 911. Paramedics arrive, and Mason is taken to
the nearest hospital emergency room and admitted. Mason died two days later from
a stroke he developed while on hemodialysis.
Source: Wilkinson et al., 2011. Reprinted with permission from the Journal of Patient
Safety .
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 45
duce muscle cramping and fatigue for
the patient.
Procedural Error 2: The vol-ume of fluid to be removed dur-ing the hemodialysis treatment.
The nurse who triaged the patient
directed that the dialysis machine be
programmed to remove 4.2 kg of
fluid (4200 mL of fluid). The error
embedded shows that the volume of
fluid programmed for removal was 42
kg. It would be deadly to remove 42
kg of fluid from any patient. The dial-ysis machine should catch and not
allow an error of that magnitude to
occur.
Procedural Error 2 was program-ming the machine to remove 42 kg of
fluid. The correct setting should have
been 4200 mL of fluid to be removed.
A setting of 42 kg would obviously be
too much (10 times the amount that
should have been removed). It would
be impossible to remove this amount
of fluid. Attempting to remove 42 kg
of fluid could cause harm to the
patient even part way through the
treatment. The harm caused could
include electrolyte imbalance, muscle
cramping, hypotension, nausea and
vomiting, and headache. In the worst
case, it could possibly result in a
patient’s death with severe dehydra-tion.
Procedural Error 3: The hepa -rin infusion rate per hour pre-scribed for the patient’s treatment.
The rate prescribed is 1500 units per
hour. The Braun machine does not
accept a rate calculated in the number
of heparin units. The machine re -quires programming of 1.5 mL per
hour. The rate shown in the scenario
is 1500, and it should be 1.5 mL. The
procedural error concerns incorrectly
cognitively converting heparin units
into mL/hour. This may be a Braun
machine-specific medical error.
Procedural Error 3 involved the
heparin administered during the
treatment. Overdosing of heparin
could prove a problem for the patient
and has been linked to fatalities in a
variety of settings. The proper setting
for heparin in this scenario would be
1.5 cc or mL per hour using 1000
units per 1 cc heparin. Heparin is
actually supplied in the clinic studied
in three dosage concentrations. The
first is 1000 units per 1 cc, the second
concentration is 5000 units per 1cc,
and the third concentration is 10,000
units per 1 cc. The obvious differ-ences in dosages are dramatic; this
could be a serious problem if not
detected and corrected by the clini-cian. After this study was conducted,
a policy change was made to pur-chase and utilize heparin only in the
1000 units per milliliter formulation.
The reasons for this change were
unrelated to the study.
Procedural Error 4: Use of the
wrong electrolyte concentrations
for the patient’s prescribed dialy -sate. Earlier in Clinical Case 1, it
states that the patient is ordered to
have a 4K, 2.5 Ca dialysate. The
dialysate of 4K has to be especially
mixed for this patient. The solutions
available in the wall outlets at this
clinic are limited to two concentration
selections of potassium solution levels
of only either 2K or 3K. Therefore, if
the dialysate is plugged into the wall
as stated in Clinical Case 1, the potas-sium could only be at a concentration
level of 2K or 3K, but not at a 4K
level. This is a potentially significant
medical error that can affect the car-diac muscle. Although outlet configu-rations and potassium concentrations
could vary in specific clinical setups,
the error here should be obvious to
every practitioner, especially due to
its potential injury severity to the sub-jects studied in the outpatient clinic
study sites.
The fourth procedural error in -volves connecting the dialysate to an
improper potassium concentration
solution. This could be a very serious
error, and the consequences can
range from tachycardia to bradycar-dia, myocardial infarction, heart
attack, or even death. The blood
maintains potassium levels within a
narrow range normally between 3.5
and 5.0 mg/dL. Either a very high or
excessively low serum potassium
level could result in death to the
patient.
Procedural Error 5: The inser-tion of the needle direction into
the fistula site. In Clinical Case 1,
the fistula needle insertion description
states that the blue line is inserted
below, and the red line is inserted
above. This is reversed, and typically
the blue or venous line is the upper
needle in the fistula and the red or
arterial line is referring to the lower or
bottom needle insertion site. This
configuration results in recirculation
of the blood.
The fifth and final procedural
medical error embedded within Clin -ical Case 1 concerns the reversal of
the direction of blood flow in the fis-tula by connecting the arterial line to
the venous side of the fistula and the
venous line to the arterial side of the
fistula. This would result in recircula-tion of the blood flow, and there
would be little or no dialysis occur-ring for the patient to remove waste
products from the bloodstream and
balance electrolytes. The outcome of
this error is in the patient not receiv-ing the benefit of dialysis from the
treatment while believing that the
blood had been dialyzed properly.
Clinical Case #2: Error
Detection and Recovery
There were two procedurally
based errors in Clinical Case 2.
Procedural Error 1: The charge
nurse should have been called
back immediately for help with a
non-responsive patient. The first of
the two embedded procedural patient
care errors in Clinical Case # 2 was
that the staff nurse should have called
the charge nurse back right away
when the non-responsive pa tient was
discovered. This patient problem was
serious enough that the charge nurse
should have been notified without
delay whether on a break or not.
Within the specific clinical setting
where the subject participants were
tested, there was a telephone exten-sion that could have been used to call
the charge nurse in the break room to
return to the patient care unit right
away. There was also an emergency
alarm button that could have been
pushed, which would have immedi-ately notified everyone in all of that
clinic’s locations that the situation was
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 46
Error Recovery by Dialysis Technicians
critical. When the emergency alarm is
pressed everyone in the building
responds.
Procedural Error 2: The pa -tient should not have been left
alone while another dialysis tech-nician retrieved the AED . A
patient in the clinical condition in
which this non-responsive patient was
found should not have been left alone
for any period of time. The staff nurse
who found the patient should have
directed one or more technicians to
bring the AED to the patient for the
safety of this potentially critically ill
patient. It was a procedural patient
care error to leave this non-respon-sive patient for any length of time.
The staff nurse should not have left a
patient in this serious condition alone.
This was a procedural patient care
error and was potentially detrimental
to the patient’s safety. The potential
consequence for leaving the patient
alone in this scenario could be severe
if the patient experiences a respirato-ry or a cardiac arrest – a code situa-tion. A trained dialysis technician
should recognize this procedural
patient care error.
Procedure
Twenty-four subjects were shown
Clinical Case # 1 with embedded pa -tient care errors and were asked to
“think aloud” as they read aloud
through the clinical case. The “think
aloud” method is widely ac cepted and
has been used successfully for over two
decades by the Patel research group.
(Patel et al., 2010). Each subject was
requested to do the following: 1) sum-marize the key points of the clinical
case from your memory without look-ing at the text again, 2) describe your
evaluation of the clinical care provid-ed to the patient, and 3) describe what
care you would give the patient with
the clinical needs presented in the
case you just read. Subjects were
asked to rate the perceived difficulty
for each case using a scale of one as
the lowest rating up to five as the
highest rating of case difficulty.
Subjects’ verbalizations were record-ed and transcribed for analysis. The
procedure was repeated for the sec-ond case. The order of the case pres-entation was varied for cross design
across subjects. Subjects were not
informed that there were clinical
errors embedded within the clinical
cases to prevent from psychologically
priming their responses. Subjects
were not asked nor directed to detect
and recover from the embedded clin-ical errors. It was predicted that dialy-sis technicians would naturally notice
and correct identified errors embed-ded in the clinical cases based on
their training and experience to look
for healthcare errors while care giv-ing.
Development and Scoring
Error Detection with Clinical
Case Template
An assessment of the number of
errors embedded within the clinical
case that were identified by each sub-ject was determined against the tem-plate. This was accomplished by
reviewing the protocol for specific
verbal statements indicating whether
the dialysis technician subject detect-ed an error set from a checklist of the
clinical case healthcare errors com-pared to the template. There were
five procedurally based healthcare
errors embedded within Clinical
Case 1 and two in Clinical Case 2.
Analysis for error recovery.
The recovery of errors was deter-mined by review of the checklist of
the embedded errors against state-ments made by the subject to recover
the errors identified. If the embedded
errors were not detected, then the
errors were assumed to not be recov-ered.
Scoring for error detection
and recovery. Each dialysis techni-cian participant was given three
scores: an error detection score, an
error recovery score, and a combined
score. The error detection score con-sisted of the number of errors detect-ed by the dialysis technician. The
error recovery score consisted of the
number of errors recovered by the
dialysis technician. The combined
score was calculated as the sum of the
error detection and recovery scores.
Statistical Analysis
The number of events and pro-portions of errors detected and recov-ered from the study were described
using means and proportions. The
analyses examine rates of error detec-tion and recovery as a function of
experience. In each analysis, the rate
examined is calculated as the number
of events (e.g., the number of proce-dural errors detected) divided by the
number of possible events (e.g., the
number of procedural errors). In all of
the analyses, P is used to denote a
proportion or rate, whereas p is used
to denote significance. The statistical
significance of differences in the rates
of errors detected and recovered was
assessed using logistic regression for
binomially distributed data. Values of
p < 0.05 (two-tails) were considered
statistically significant. All analyses
were conducted using SAS 9.2.
Results
The 24 dialysis technician partic-ipants included 18 females and six
males. Eight dialysis technicians were
21 to 30 years of age, four were 31 to
40 years of age, seven were 41 to 50
years of age, and five were 51 to 60
years of age or older. Twenty dialysis
technicians worked in the outpatient
hemodialysis areas, and four worked
in the inpatient hospital unit. Sixteen
dialysis technicians were certified
technicians, and eight were not certi-fied (see Table 3). Analyses of rates of
error detection and rates of error re -covery for gender, age category, work
site, and certification status showed
no significant differences between
these characteristics or groups.
Logistic regression was per-formed to determine whether there
were any differences between the
experts and non-expert dialysis tech-nicians for the combined rate of
errors detected and recovered. Logi -stic regression showed that expert
dialysis technicians ( P = 0.340) had a
significantly higher combined rate of
error detection and recovery than
non-expert dialysis technicians (P =
0.227) (χ
2
[1] = 7.22, p < 0.01) (see
Table 4). The difference between ex –
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 47
pert dialysis technicians (P = 0.357)
and non-expert dialysis technicians (P
= 0.214) for procedural errors detected
was not significant (χ
2
[1] = 3.36, p =
0.07) (see Table 5). There was a signif-icant difference between expert dialy-sis technicians ( P = 0.333) and non-expert dialysis technicians (P = 0.183)
for procedural errors recovered (χ
2
[1] =
4.05, p < 0.05) (see Table 6).
The interaction of dialysis experi-ence was examined through a multi-level logistic model because error type
is a within-subjects measure. The inter-action was not significant for the com-bined rate of detections and re coveries
(F[1,19.49] = 0.14, p = 0.71). The inter-action was also not significant for
detections alone (F[1,19.71] = 0.1, p =
0.76) or for recoveries alone (F[ 1,18.42]
= 0.10, p = 0.75). Inter action testing of
“detection and recovery” as a function
of dialysis experience revealed no sig-nificant difference between detec-tions and recoveries by experience
(F[1,21.8 3] = 0.11, p = 0.74).
Procedural Errors-Results
Clinical Case 1. Procedural
Error 1: Entering an incorrect
extended amount of time for dial-ysis treatment. Of the 24 dialysis
technicians, five subjects detected the
error, and all of those addressed
recovering it. Four dialysis techni-cians who detected this error were
experts, and one was not.
Clinical Case 1. Procedural Er -ror 2: Incorrect fluid volume for
removal programmed into the
dialysis machine. Four of the 24 sub-jects detected the error, and two of
these recovered from the error. Of the
two dialysis technicians who recov-ered this error, one was an expert and
one was not.
Clinical Case 1. Procedural Er -ror 3: Incorrect heparin infusion
rate programmed into the dialysis
machine.Three of the 24 dialysis
technicians detected this error, and
one of them recovered it. The one
who recovered it was an expert.
Clinical Case 1. Procedural Er -ror 4: Connection of the dialysate
lines to an incorrect potassium
bath concentration. Three of the 24
Table 3
Demographic Data
Gender Age Work Site Certification
Expert
Dialysis
Technicians
Female – 6
(100%)
Male – 0
(0%)
21 to 30
0 (0%)
31 to 40
2 (33%)
41 to 50
1 (17%)
51 to 60+
3 (50%)
Out patient –
5 (83%)
Inpatient
1 (17%)
Yes – 6
(100%)
No – 0 ( 0%)
Non-Expert
Dialysis
Technicians
Female – 12
(77%)
Male – 6
(33%)
21 to 30
8 (45%)
31 to 40
2 (11%)
41 to 50
6 (33%)
51 to 60+
2 (11%)
Out patient –
15 (83%)
Inpatient
3 (17%)
Yes – 10
(56%)
No – 8 (44%)
Table 4
Combined Rate of All Errors Detected Plus Errors Recovered
N Combined Mean t-Statistic Significance
Expert
Dialysis Technicians
6 0.340
7.22 p < 0.01, df =1
Non-Expert Dialysis
Technicians
18 0.227
Table 5
Rate of Procedural Errors Detected
N Mean t-Statistic Significance
Expert
Dialysis Technicians
6 0.357
3.36 p < 0.07, df = 1
Non-Expert Dialysis
Technicians
18 0.214
Table 6
Rate of Procedural Errors Recovered
N Combined Mean t-Statistic Significance
Expert
Dialysis Technicians
6 0.333
4.05 p < 0.05, df = 1
Non-Expert Dialysis
Technicians
18 0.183
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 48
Error Recovery by Dialysis Technicians
dialysis technicians detected this
error. Two experts and one non-expert detected it. The two who
recovered it were both experts.
Clinical Case 1. Procedural Er -ror 5: Reversal of the fistula lines.
For this error, nine of the 24 dialysis
technicians detected the error, and all
of them recovered it. Three dialysis
technicians were experts and six were
non-experts.
Clinical Case 2. Procedural Er -ror 1: The charge nurse should
have been called back immediate-ly for help with a non-responsive
patient. The 14 dialysis technicians
who detected this error also recov-ered it. Four of those dialysis techni-cians were experts, and two were not.
Clinical Case 2. Procedural Er -ror 2: The patient should not have
been left alone while another
dialysis technician retrieved the
AED. Of the 24 subjects, four detect-ed and recovered the error. Two dial-ysis technicians were experts, and two
dialysis technicians were non-experts.
All dialysis technicians who detected
this error recovered it.
Discussion
Findings of this study show a sig-nificant difference between the expert
and non-expert dialysis technicians for
recovering from procedurally based
errors embedded within the two cases
presented to the participants. Both
groups were able to detect errors
equally well, but experts were able to
recover from the errors more fre-quently than non-expert dialysis tech-nicians. Therefore, the important
aspect of the effect of training is cor-recting the errors generated and not
just detecting them or not making any
errors. We observed that experience
gives experts this error recovery
advantage. These findings are consis-tent with research in which experts in
other fields were found to have more
numerous and efficient strategies for
superior recovery of detected errors
(Amalberti, 2001; Patel & Cohen,
2008; Patel et al., 2010). One recent
study found that physicians recovered
errors within a clinical simulation sig-nificantly better when they were
“primed” (i.e., informed in advance)
that errors existed within the research
cases presented, allowing for more
vigilant error detection and correc-tion than did the non-primed physi-cian comparison group (Razzouk,
Cohen, Almoosa, & Patel, 2011).
Our observations show that the
training and job-related experiences
of non-expert and expert dialysis
technicians enable them to be equally
effective in detecting errors during
hemodialysis care delivery. There -fore, it may be appropriate to focus
more time on continuing education
for the non-expert technicians regard-ing error recovery strategies to elimi-nate or mitigate errors in progress
detected during dialysis treatment
(Patel et al., 2010). Review of the pro-tocol transcripts showed the same pat-tern as Patel et al. (2010) found with
physicians where experts fixed errors
immediately when they detected them
and non-experts had to finish the
entire case review to assimilate the
entire case facts before they were able
to detect the embedded errors. Errors
must first be detected before they can
be recovered.
All dialysis technicians in this
study had uniform training in the
Arizona dialysis company in which
dialysis technicians were studied for
their ability to detect and recover er -rors. Information concerning the pre-vious experience or additional train-ing of the dialysis technicians was not
obtained in the present study. All dial-ysis technicians in the study had the
same standard training program, but
after 10 years or more of practice,
there was a significantly different per-formance level found in this study for
the recovery of the procedurally bas -ed errors, while no differences were
found for the detection of procedural-ly based errors.
One reason for these findings
could be that the use of a laboratory-based assessment method by itself
without the multilevel simulation of
real-time, live patient care is inade-quate to detect the true ability of dial-ysis technicians to detect and recover
procedurally based errors. Training
has to be based on real-world practice
in complex settings with specific tasks
that are more likely to generate
errors. Clinicians also need to have
the knowledge of the procedures to
be able to correct the errors they
make. A second reason could be that
the initial orientation and training
program is sufficient to teach dialysis
technicians about the procedurally
based errors looked at in this study,
and there is no perceived need for
growth in their dialysis practice
regarding error detection to perform
their jobs sufficiently well. After all,
there was a low threshold of error
detection across the entire study
group in this study, similar to the one
in the Patel et al. (2010) study, which
reported that doctor participants also
identified less than half of the errors
present using similar methods as did
the Wilkinson et al. (2011) study,
which evaluated nurses working in
hemodialysis units.
At the sites studied, a focus on
continued training for procedurally
based knowledge and skills develop-ment is provided and encouraged
because it is necessary for profession-al growth in this area to improve the
ability of dialysis technicians to care
for patients on dialysis. The initial
training is deemed sufficient to prac-tice at a minimum safe level. Based
on our research findings, we believe
that specialized continuing education
programs that focus on the recovery
strategies for recognized dialysis pro-cedurally based errors are needed to
enhance the ability of dialysis techni-cians to better recover observed and
detected errors. “The ‘little’ errors
and omissions to which we may have
become too accustomed or let slide
by, in reality, can easily become big
problems for our patients, or at the
least, such an attitude can create an
environment that is too laissez-faire
for safe patient care. This is a chal-lenge that deserves our best efforts.
Keeping patients safe and unharmed
has been a basic tenet of our profes-sion since the profession began. When
it comes to patient safety, we need to
take the lead” (Ulrich, 2008, p. 237).
“Let’s take back our right (and res –
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 49
ponsibility) as registered nurses to
take action to keep patients safe”
(Payne, 2012, p. 97). Nurses need to
take the lead for training dialysis tech-nicians to make patient safety their
priority. Error risk mitigation strate-gies are essential for dialysis techni-cians to know, understand, and im -plement. Educational enrichment of
error recovery strategies can lead the
way for less adverse event outcomes
for patients on dialysis.
Limitations
The findings and conclusions of
this research are limited to dialysis
technicians to one dialysis company
in Arizona. This study was limited to
laboratory-based evaluation of error
detection and recovery. The impact
of real-time error detection and
recovery was not possible in the labo-ratory setting. The interaction of team
members to detect and recover was
not assessed in this research. Because
this study was cross-sectional, growth
in skill could not be tested directly to
assess differences of time. A larger
sample size is needed to verify these
results.
Conclusions
Expert dialysis technicians with
10 or more years of dialysis experi-ence are able to recover errors better
than non-expert dialysis technicians.
However, expert and non-expert dial-ysis technicians detect errors equally
well. Both groups can detect, but only
the experts can correct errors more
effectively. Dialysis technician patient
care practice is primarily procedural
in nature. Adequate training of dialy-sis technicians that enables them to
detect errors like an expert dialysis
technician earlier as a non-expert
dialysis technician presently exists.
Therefore, continuing training pro-grams for dialysis technicians might
be more productive in terms of
improving patient safety if they are
focused more on elucidating specific
strategies to recover errors that have
been detected already with less atten-tion directed toward the detection of
errors alone. Specially developed
dialysis technician continuing educa-tion programs to promote growth of
dialysis technicians error recovery
strategy techniques and strategies in
dialysis are recommended.
Some studies by Patel and her
group are under way where error
recovery intervention studies are
being conducted in critical care in a
simulated program for intensive care
conditions (Razzouk et al., 2011).
These studies can also be extended
for training and evaluation in the dial-ysis technicians’ environment. The
basic assumption underlying the in -tervention is that repeated training in
detection and also in recovery strate-gies for errors are as close to real envi-ronment (simulation) and should
improve this strategy. Further studies
to improve error recovery training
and education through such interven-tion studies and performance assess-ment will go a long way in improving
safety for patients on hemodialysis.
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The human factor: the critical importance of effective
teamwork and communicatio n in providing safe care
M Leonard, S Graham, D Bonacum
……………………………………………………………………………………………………………….
Qual Saf Health Care2004; 13(Suppl 1):i85–i90. doi: 10.1136/qshc.2004.010033
Effective communication and teamwork is essential for the
delivery of hig h quality, safe patient care. Communi cation
failures are an extremely commo n cause of inadvertent
patient harm. The complexity of medical care, couple d with
the inherent limitations of human performance, make it
critically important that clin icians have standardised
communication tools, create an envir onment in which
individuals can speak up and express concerns, and share
common ‘‘critical language’’ to alert team members to
unsafe situations. All too frequentl y, effec tive
communication is si tuation or personali ty dependent. Other
high reliability domains, such as commerc ial aviation, have
shown that the adoption of standardised too ls and
behaviours is a very effective strategy in enhancing
teamwork and reduci ng risk. We describe our ongoing
patient safety implementation using this approach within
Kaiser Permanente, a non-profit American health care
system providing care for 8.3 million patients. We
describe spe cific clinical experienc e in the application of
surgical briefings, prope rties of high reliability perinatal
care, the value of critical event training and simulation, and
benefits of a standardis ed communication process in the
care of patients transferred from hospitals to skilled nursin g
facilities. Additionally, lessons learned as to effective
techniques in achieving cultural change, evidence of
improving the quality of the work environ ment, practice
transfer strategies, critical success factors, and the evolving
methods of demonstrating the benefit of such work are
described.
…………………………………………………………………
See end of article for
authors’ affiliations
…………………..
Correspondence to:
Dr M Leonard, Physician
Leader for Patient Safety,
Patient Safety, One Kaiser
Plaza, 22nd Floor,
Oakland, CA 94612,
USA; mmleonard@att.net
…………………..
C
ommunication failures are the leading
causes of inadvertent patient harm.
Although medical care is delivered by
multiple team members, medical quality and
safety has historically been structured on the
performance of expert, individual practitioners.
Effective communication and teamwork have
been assumed, and formal training and assess-ment in these areas has been largely absent.
Appreciation that the clinical care environment
has become progressively more complex, com-bined with the inherent limitations of human
performance, has spurred interest in applying the
lessons of other high reliability industries to
medicine.
The development and implementation of crew
resource management (CRM) in aviation over
the last 25 years offers valuable lessons for
medical care. Realising that 70% of commercial
flight accidents stemmed from communication
failures among crew members, CRM sought to
standardise communication and teamwork.
Currently, CRM is required globally in aviation
training, and direct observational studies by
Robert Helmreich’s group have correlated actual
flight crew performance with attitudes toward
teamwork and safety. In 2000, we undertook the
adoption of relevant behaviours and skills into
high risk medical environments. Twelve clinical
teams underwent a three day training pro-gramme in human factors; learning about the
human factors experience in aviation, and the
application of standard tools and behaviours to
improve safety and ensure effective communica-tion. The teams each worked on a clinical project
in which these techniques could be applied to
improve the quality and safety of patient care.
The clinical domains represented varied widely
from the operating room, the intensive care unit,
and continuing care (the transfer of patients
from hospitals to skilled nursing facilities), to
obstetrics and a cardiac treadmill unit.
After the initial training, the clinical teams
were supported with site visits and educational
sessions for leadership and clinicians within the
facilities. Cultural surveys with regard to safety
were carried out using the Safety Attitude
Questionnaire (SAQ).
1
Valuable insights into
the climate in these care areas with regard to
teamwork, communication, and attitudes toward
safety were obtained. Gathering intimate knowl-edge of the specific culture allowed interventions
that focused on the strengths of the team and
targeted opportunities for improvement.
Monthly conference calls helped create a colla-borative community dedicated to improving
safety, and to sharing successes and approaches
to the inevitable barriers.
Our experience has reinforced the belief that
simple rules are best for managing complex
environments. The tools and concepts that have
proven the most valuable are collectively know as
SBAR (situation, background, assessment,
recommendation): a situational briefing model,
appropriate assertion, critical language, and
awareness and education regarding the fact that
nurses, physicians, and other clinicians are
taught to communicate in very different styles.
Abbreviations: CRM, crew resource management; OR,
operating room; PIC, preferred intensity of care; SAQ,
Safety Attitude Questionnaire
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We will discuss these tools and our experiences in optimising
successful implementation, and describe experiences in
specific clinical areas. Other valuable concepts such as
situational awareness and debriefing will be mentioned.
THE CASE F OR A PRIMARY FOCUS O N EFFECTIVE
TEAMWORK A ND COMMUNIC ATION
Communication failures are the leading cause of inadvertent
patient harm. Analysis of 2455 sentinel events reported to the
Joint Commission for Hospital Accreditation revealed that
the primary root cause in over 70% was communication
failure. Reflecting the seriousness of these occurrences,
approximately 75% of these patients died.
2
All too often,
clinicians providing care had very divergent perceptions of
what was supposed to happen. Effective communication and
teamwork is aimed at creating a common mental model, or
‘‘getting everyone in the same movie’’. Equally important is
creating an environment that feels ‘‘safe’’ to team members
so they will speak up when they have safety concerns. The
mantra of ‘‘everyone in the same movie, and no surprises’’ is
an effective one that is easy to teach. Clinicians understand
that surprises in medicine are generally not good.
Many factors contribute to communication failures. First
and foremost, doctors and nurses are trained to communicate
quite differently. Nurses are taught to be very broad and
narrative in their descriptions of clinical situations (‘‘paint
the big picture’’), whereas physicians learn to be very concise,
and get to the ‘‘headlines’’ quite quickly. Nurses often relate
being told during their educational process that they ‘‘don’t
make diagnoses’’. This leads to nurses telephoning physicians
and being very broad and narrative in their descriptions, with
the doctors impatiently ‘‘waiting to find out what they
want’’. SBAR is very effective in bridging this difference in
communication styles and helping to ‘‘get everyone in the
same movie.’’
Hierarchy, or power distance, frequently inhibits people
from speaking up. Effective leaders flatten the hierarchy,
create familiarity and make it feel safe to speak up and
participate. Authoritarian leaders, reinforcing large authority
gradients, create unnecessary risk. The lack of standardised
communication and procedures in medicine increases the
importance that team members invest in creating a common
mental model; otherwise, there is limited ability to predict
and monitor what is supposed to happen. Many of the
current Joint Commission Patient Safety Standards are
aimed at structuring and improving communication.
3
A large and ever present cultural barrier is the deeply
embedded belief that quality of care and error free clinical
performance are the result of being well trained and trying
hard. In this paradigm, inevitable mistakes are viewed as
episodes of personal failure, with the predictable result that
these events are minimised and not openly discussed. Human
factors science tells us that the inherent limitations of human
memory, effects of stress and fatigue, the risks associated
with distractions and interruptions, and limited ability to
multitask ensure that even skilled, experienced providers will
make mistakes. As such, effective communication that
creates a well understood plan of care greatly reduces the
chances of inevitable errors becoming consequential and
injuring patients.
TOOLS AND BEHAVIOURS FOR EFFECTIVE
COMMUNIC ATION
Briefings, although standard practice in aviation, the
military, and law enforcement, have been uncommon in
clinical medicine. Spending a few minutes at the beginning
of a shift can get everyone at the same startpoint, avoid
surprises, and positively affect how the team works together.
SBAR is a very effective tool that provides a common and
predictable structure to the communication. It can be used in
virtually any clinical domain, and has been widely applied in
obstetrics, rapid response teams, ambulatory care, the ICU,
cardiac arrests, and other areas.
SBAR stands for: (i) situation 2 what is going on with the
patient?; (ii) background2 what is the clinical background,
or context?; (iii) assessment 2 what do I think the problem
is?; and (iv) recommendation 2 what would I do to correct
it?
A clinical example:
N
Situation: ‘‘Dr Preston, I’m calling about Mr. Lakewood,
who’s having trouble breathing.’’
N
Background: ‘‘He’s a 54 year old man with chronic lung
disease who has been sliding downhill, and now he’s
acutely worse.’’
N
Assessment ‘‘I don’t hear any breath sounds in his right
chest. I think he has a pneumothorax.’’
N
Recommendation ‘‘I need you to see him right now. I
think he needs a chest tube.’’
Briefly and concisely, critically important pieces of infor-mation have transmitted in a predictable structure. Not only
is there familiarity in how people communicate, but the
SBAR structure helps develop desired critical thinking skills.
The person initiating the communication knows that before
they pick up the telephone that they need to provide an
assessment of the problem and what they think an
appropriate solution is. Their conclusion may not ultimately
be the answer, but there is clearly value in defining the
situation.
Ap pr op ri at e a ssert i on
Teaching people how to speak up and creating the dynamic
where they will express their concerns is a key factor in
safety. Frequently, the lack of a common mental model or
hierarchy gets in the way. People need to state the problem
politely and persistently until they get an answer (fig 1); the
common practice of speaking indirectly (the ‘‘hint and hope’’
model) is fraught with risk. Focusing on the problem and
avoiding the issue of who’s ‘‘right ‘‘and who’s ‘‘wrong’’ is
quite important and a major success factor.
One point is worth clarification. We often ask or require
nurses to provide an objective argument to convince a
physician to see a patient. Given the differences in commu-nication style between the two groups, requiring nurses to
provide a concise, cogent argument as to the severity of the
patient’s condition, and basing the physician’s response time
on this, is fraught with hazard. A better approach, and
standard practice in our perinatal safety work, is that nurses
have license to say: ‘‘I need you to come now and see this
Get person’s
attention
Reach
decision
Express
concern
State
problem
Propose
action
Figure 1 Assertion cycle. This is a model to guide and improve
assertion in the interest of patient safety.
i8 6 Leonard, Graham, Bonacum
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patient’’, and the physician responds every time. The
situation is not open to argument at the time that the
request is made, particularly at night or at weekends; if the
relationship needs to be reassessed, that can be carried out
sometime in the future when people can be more objective.
Making it acceptable for the nurse to say: ‘‘Something’s
wrong, I’m not sure what it is, but I need you here now’’ is an
effective mechanism to ensure safety. Coupling this with
SBAR helps ensure that communication becomes progres-sively clearer.
In a recent study of medical emergency teams from
Australia that demonstrated an in hospital cardiac arrest
reduction of 65% through early intervention, the number one
criterion to call for help was ‘‘a staff member is worried about
the patient’’.
4
There were also numerous objective measures
of physiological distress, but the ability of someone to seek
prompt and expert help because ‘‘it doesn’t feel right’’ is a
very insightful mechanism. Gary Klein’s work in naturalistic
decision making has shown that expert individuals rapidly
analyse situations by pattern matching against their mental
library of prior experience.
5
Thus, a nurse at the bedside may
not be able to put a concise label or description on what is
clinically unfolding, but very probably knows ‘‘something is
wrong, and I need your help’’. Lowering the threshold to
obtain help, and treating the request respectfully and
legitimately creates a much safer system.
Crit ical l an guage
Medicine is a hierarchical environment, in which it can be
difficult for people to speak up with concerns. Additionally,
power distances, lack of psychological safety, cultural norms,
and uncertainty as to the plan of action further complicate
the situation. The adoption of critical language, derived from
the CUS programme at United Airlines, is very effective. CUS
stands for ‘‘I’m concerned, I’m uncomfortable, this is unsafe,
or I’m scared’’, and is adopted within the culture as meaning:
‘‘we have a serious problem, stop and listen to me’’. This
ability to get everyone to stop and listen is essential for safe
care. Critical language creates a clearly agreed upon commu-nication model, that helps avoid the natural tendency to
speak indirectly and deferentially.
Situat ional a wareness
Situational awareness refers to the care team maintaining the
‘‘big picture’’ and thinking ahead to plan and discuss
contingencies. This ongoing dialogue, which keeps members
of the team up to date with what is happening and how they
will respond if the situation changes, is a key factor in safety.
The value of maintaining situational awareness has been
studied in high risk neonatal cardiac surgery by Marc DeLeval
and his colleagues at Great Ormond Street Hospital in
London.
6
De b r ie fin g
Debriefing is the process of spending a couple of minutes
after a procedure, or at the end of a day, to assess what the
team did well, what were the challenges, and what they will
do differently the next time. It is a great opportunity for both
individual and team learning while the events are fresh. In a
study of team learning in the adoption of minimally invasive
cardiac surgery, debriefings were seen as one of the key
success factors in the surgical team with the quickest
learning curve and best clinical outcomes.
7
EXAMPLES OF CLI NICAL PROJECTS FOCUSING ON
TEAMWORK A ND COMMUNIC ATION
Pe rin at al sa fe t y
Catastrophic birth injury is rare in the experience of a single
practitioner, and may be a once in a career event. However, a
limited number of clinical situations (fetal distress, the need
for an emergency caesarean section, shoulder dystocia,
placental abruption, and massive maternal haemorrhage)
account for a very high percentage of recurrent events.
8
Invariably, poor outcomes are accompanied by fundamental
communication failures.
One scenario that illustrates the importance of effective
communication is the ‘‘myth of the low risk delivery’’ (Dr
Eric Knox, personal communication). A healthy mother and
fetus arrive in labour. If either the mother or the fetus were
high risk, everyone would be aware that a potential problem
exists. In the case of the low risk parturient, complacency can
be very dangerous, because of the attitude of ‘‘we’ve done
this thousands of times and never had a problem’’. In the
small percent of these labours that develop a problem, a
critical juncture occurs when the nurse has to deal with a
physician perceived to be unpleasant or difficult to approach.
Reflecting human nature, the nurse will try to correct the
problem themselves, and avoid a potentially unpleasant
interaction. Most of the time this approach works, but in
the case where there is now more of a problem, the next
interaction is really critical. When the nurse approaches the
physician for help and gets the answer ‘‘try these three things
and call me in an hour’’, the stage is set for a disaster.
E xperience from Kaiser Permanente
Kaiser Permanente is the largest, non-profit health system in
America, founded over 50 years ago. It is an integrated care
model that has 135 000 employees, more than 11 000
physicians, and provides medical care for some 8.3 million
patients.
In the Kaiser Permanente perinatal work, the practice has
been instituted that if a nurse or midwife is concerned, she
can say to the physician ‘‘I need you now’’ and they will
attend 100% of the time. Teams have standardised the use of
SBAR as the model for communication. Additional work has
been carried out to define fetal wellbeing, and to have a
common approach to the interpretation of fetal heart tracing
and practice for emergencies.
A good example of standardising response is illustrated by
the work of Michael Fox, RN.
9
He has adopted a method of
fetal heart rate interpretation to enable medical staff such as
doctors, nurses, midwives and medical students, to use a
common language to optimise the chances of problem
recognition. Once fetal distress has been identified, very
simple and effective rules are activated: if you see a problem,
you have 1 minute to look at by yourself; 2 minutes to look at
it with someone else; and by minute three you are physically
on your way to correcting the problem. These simple rules
provide predictability; they remove the ‘‘grey area’’ of how
the nurse or midwife should respond (what’s the urgency, is
the doctor busy, should I call him?) 2 all the potential
judgements that contribute to long delays in addressing fetal
asphyxia. Not only is the response clear, but everyone knows
the rules.
Standardised communication at shift changes has been
implemented, with doctors and nurses all in the conversa-tion, in contrast to prior practice where physicians and nurses
reported to their peers separately and at different times.
Briefings using SBAR are used for the team to quickly
reassess the if the clinical workload increases or people are
getting overloaded: ‘‘Let’s talk a minute and go over all the
patients on the deck 2 who’s got what patient, where are we
with each patient, what are the issues that need to be
addressed, and how do we prioritise?’’. Very quickly, the care
team can ensure they are all ‘‘on the same page of the script’’
and all relevant clinical issues are being addressed.
Critical event training or simulation is a valuable tool. Low
fidelity simulation can be carried out by physically walking
through the unit and mapping all the tasks that have to be
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done in the event of an emergency caesarean section: who
needs to be called, what resources need to be activated
(paediatrics, the nursery), and where is the equipment we
will need? Midrange fidelity simulation uses a manikin
simulator driven off a laptop computer. The team is
challenged with various clinical scenarios and their response
is videotaped for debriefing. Trust that the goal is on non-judgmental learning is critically important for credibility of
the training process. Focusing on the complexity of the care
process and the system flaws that set ‘‘good people up to fail’’
creates psychological safety, which is a key component of
learning.
Patient transfer
Experienc e f rom Kaiser Font ana: benefits from th e
use o f a c hecklist a nd br ief ing in pat ients t ran sf err e d
fr om the hospital to skilled nursing faci lities
Dr Thomas Cuyegkeng and his colleagues at Kaiser Fontana
undertook a process to improve the transfer of elderly
patients from the hospital to skilled nursing facilities.
Commonly, patients arrived at night (owing to available
ambulance resources) and the breakdown in communication
resulted in important medications such as anticoagulants,
antibiotics, analgesics, and psychotropics being unavailable.
This is a complex patient population, comprising people who
are often frail and taking multiple medications. A common
problem with patients arriving with incomplete information
at night was that no one familiar with the patient was
available to reconcile clinical issues. The Fontana team
implemented two checklists; one to be completed in the
hospital and one by the skilled nursing facility. This briefing
was carried out nurse to nurse over the telephone with the
requirement that any gaps or discrepancies be reconciled
prior to 5 pm, so people familiar with the patient would be
available to help. The team also recharacterised the process
and changed it from a discharge to a transfer, to reinforce the
concept that the clinicians had an ongoing responsibility to
provide accurate information and quality care. A critical
forcing function was put into the system: unless the checklist
was completed by the transferring physician, the patient
could not physically leave. This created a clear incentive for
the physicians to get it right, otherwise the patient remained
on their service. The result was a dramatic increase in the
percentage of patients having necessary medications on
arrival in the skilled nursing facility. The following table
shows the improvement in providing information in both the
hospital and skilled nursing facility (table 1).
Another interesting facet was that the process defined the
preferred intensity of care (PIC), the conditions under which
the patient or their family desired rehospitalisation and what
level of care was desired. All too frequently, patients would
become ill in the middle of the night or on weekends, when
the skilled nursing facility staff coverage is at a minimum,
and the chances of the covering physician knowing the
patient are least. These chronically ill patients would be sent
by ambulance to the nearest emergency department, where
they would then receive extensive investigations and/or end
up in the intensive care unit; exactly what the patient and
their family did not want. By increasing the percentage of
patients where the PIC was defined, the team estimated they
were saving some 50 unwanted hospital readmissions
annually across a patient population of 300 000 patients,
and saving patients from being subjected to unwanted
medical care.
Perioper at ive bri efings
At Orange County Kaiser, surgical teams introduced for-malised briefings into their care process. The critical success
factors were clear, and there was visible physician leadership
and involvement throughout, and an inclusive process that
engaged people in the determination of what the briefing
content should be. Developing the Orange County briefing
tool involved surgeons, anaesthetists, operating room nurses
and technicians, and managers, all working together. The
briefing categories were broken into four sections. The
surgical category began with the surgeon telling the others
what he/she thought they needed to know in a given case. It
was then everyone else’s turn to tell the surgeon what they
needed to know. For example, the operating room (OR)
nurses wanted to know if the surgeon was on call, as they
would have to answer the surgeon’s pager frequently during
the case; the surgeons were visibly surprised to learn how
much impact this would have on the nurses during the
surgery. Although these people had worked, or physically
shared space, for years together, they discovered basic
insights into how their behaviour or transfer of information
affected others.
The briefing chart shown is the third iteration developed by
the OR team (fig 2). It is a template showing the potential
topics for the surgical team to cover, which they use as
relevant to the case at hand. The team decided that they
would brief after the patient had been anaesthetised, that
being the only time they consistently have all members of the
team physically present. Other facilities, believing that it is
preferable to brief prior to the induction of anaesthesia, have
chosen to brief in the operating room with the patient awake.
The initial concern that briefing with the patient might infer
from this that the team did not know what they were doing
has not been borne out; early indications are that patients
really like the process. It is presented to the patient as a last
opportunity for the surgical team to make sure they are all
‘‘on the same page’’ and doing everything correctly.
The Orange County results have been quite positive. Wrong
site surgeries, which had been a problem in the past, have not
occurred since the briefing process has been initiated.
Nursing turnover has fallen by 16%. As measured by the
SAQ, employee satisfaction has increased by 19%, and
perceptions of safety climate in the OR have gone from
‘‘good’’ to ‘‘outstanding’’. Significant improvements were
also seen in teamwork climate, communication, OR person-nel taking responsibility for patient safety, and medical errors
being handled appropriately. After implementation, some
80% of OR nurses reported that their input was well received
by other team members. The briefing process has been
Table 2 Hospital and nursing facility checklists
Baseline
31 De c –
24 Jan
25 Jan –
18 Feb
19 Feb –
15 Mar
Hospi tal checkli st – RN
No. of patient s 59 71 84 72
Code status 86% 92% 75% 89%
PIC 14% 92% 75% 89%
Antigo agulant check 24% 48% 29% 100%
Special abx chec k 15% 55% 19% 100%
Pain rx check 20% 54% 41% 79%
Y rx check NA 27% 28% 100%
Special needs 60% 19% 24% 70%
Final RN chec k NA 24% 24% 80%
Nursing facilit y checklist
No. of patient s 59 30 25 6
RN repor t 0% 70% 80% 100%
Faxed orders 85% 76% 96% 100%
Code status 86% 93% 96% 100%
PIC 14% 47% 76% 100%
Pain meds available 12% 40% 88% 44%
Psychot ropics
ava ilable
NR 25% 70% 88%
*n = 227; from Fontana Hospital only (n = 71 ; 31% sample of 227
patients). PIC, preferred intensity of care; a bx, an tibiotics; rx, therapy or
medicat ions;Y, psychotr opic.
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transferred within their hospital to the Departments of
Radiology, and Labour and Delivery. Currently, the plan is
to now begin looking at the efficiency of the OR and see how
preoperative communication failures—that is, last minute
surprises where the team finds out that they need particular
equipment, people or skills present, are precluded by more
effective communication patterns.
CRITICAL S UCCESS FACTORS
Through this experience in teamwork and communication
training and clinical projects, certain critical success factors
have become clear. It is essential to approach medical culture
from a ‘‘bottom up’’ perspective. Traditional improvement
efforts have been seen as ‘‘top down’’—that is, ‘‘you have a
problem that needs to be corrected’’. This message will be
immediately and vigorously rejected by the culture, which
will then actively work against the desired change. A
critically important element is to dissociate the inevitable
errors and communication failures associated with human
performance from the issue of clinical competency.
Approaching improvement from the perspective of correcting
system flaws and using standardised communication tools to
make the day go more smoothly and keep everyone safe is
effective. The message of ‘‘good people are set up to fail in
bad systems—let’s figure out how to keep everyone safe’’ is
readily accepted. Spending time to educate clinicians about
the prevalence of system error, and the inherent limitations
of human performance, help dissociate error from the
common perception of mistakes being episodes of personal
failure.
Two absolute requirements for successful clinical change
are visible support from senior leadership and strong clinical
leadership. In medical culture, physicians who stand up and
say ‘‘this is the right thing to do, I support it and you need to
also’’ have great impact. Others who wait to see if the projects
are successful before being publicly associated with them
leave nurses and others to push change uphill against the
hierarchy; predictably, these efforts are usually less success-ful. Embedding the changes in the clinical work is essential.
The changes need to be perceived as making the day simpler,
safer, and easier for everyone. Once the case has been made
for change, then having a very clear focus, taking ‘‘one bite of
the elephant at a time’’, getting finite time commitments
from the people involved, and measuring and celebrating
success are all important components.
This work has been approached from the perspective of
defining the practical successful elements that can be spread
across our larger care system. The perinatal safety and
perioperative briefing elements described above are now
being actively transferred. Multidisciplinary teams from
across the organisation have been brought together for
educational sessions interacting with the clinical sites that
implemented these tools and behaviours. The teams are then
supported with educational materials, site visits, and ongoing
collaborative calls as they proceed with implementation. It is
our belief that this process accelerates clinical learning and
implementation.
DI SCUSSION
We have described the experience to date with human factors
training focusing on teamwork and communication within a
large, non-profit American health system. The experience to
date has shown us the value of embedding standardised tools
and behaviours into the care process to improve safety in a
progressively more complex care environment. Many of the
lessons demonstrating the value of such techniques have
been learned in other high reliability industries over the last
few decades, and they offer a valuable resource for medicine
today.
Cultural change is at the heart of this quest; transforming
care from the culture of the individual expert physician to a
truly collaborative team environment. Not only do differences
in communication styles between physicians, nurses, and
others impede this aim, but the complexity of the care
Anesthesia
Figure 2 Kaiser Orange County
Briefing.
Eff ective team work and c omm u ni cati on in pro vidi ng safe c are i 89
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process has made effective communication paramount for
safe care. The literature is replete with the frequency and
potential devastation of clinical communication failures. For
this cultural change to be successful, leadership and
physician involvement is critical. Changes need to be
embedded in the clinical work, and perceived as providing
benefit, not more work to do. Projects need to be clearly
focused, so people doing the work can see the benefit of their
efforts. This is not a linear process, so flexibility and the
ability to adapt to operational pressures and local cultures are
important.
To date, we are seeing that teaching and embedding a few
basic tools and behaviours can provide tremendous clinical
benefit. We have seen improved cultural measures 2
attitudes surrounding teamwork and safety climate. As
mentioned, these measures have been strongly linked in
aviation to actual flight crew performance through direct
observation and survey instruments.[10] The development
of direct observational markers that assess both task
performance and the team behaviours of the clinicians
working together is currently in progress. Ultimately, our
goal is to show a reduction in adverse events and better
clinical outcomes through the adoption of these tools and
behaviours. A large integrated system such as Kaiser has the
potential to measure infrequent events across a large
population, and potentially demonstrate a positive impact
on their frequency. Although still early in the journey, this
patient safety work shows great promise in both enhancing
the safety of care and improving the work environment for
our clinicians.
ACKNOWLEDGEMENTS
We wish to attribute and credit the following individuals for their
work in the following areas. Perinatal safety: P Preston, B Merl, S
McFerran, J Nunes, J Derrough, R Fields, G Escobar, E Thomas and
others; continuing care transfers: T Cuyegkeng, M Rathfelder, S
Caulk, A Scott, B Mahoney; and perioperative briefings: J DeFontes,
M Gow, M Vanefsky, S Scott, K Dower, S Surbida, L Fuller.
Authors’ affiliations
…………………
M Leonard, Colorado Permanente Medical Group, Denver, Colorado,
OH, USA
S Graham, California Kaiser Permanente, Oakland, CA, USA
D Bonacum,Kaiser Permanente, Oakland, CA, USA
Competing interests: none declared
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50 7.
Key mess ages
N
Communication failures account for the overwhelming
majority of unanticipated adverse events in patients.
N
Medical care is extremely complex, and this complexity
coupled with inherent human performance limitations,
even in skilled, experienced, highly motivated indivi-duals, ensures there will be mistakes.
N
Effective te am work and communi cation can h elp
prev ent these inevitable mistakes from becoming
consequential, and harming patients and providers.
N
Embedding standardised tools and behaviours such as
SBAR (a situational briefing model ), appropriate
assertion, and critical language can greatly enhance
safety. These tools can effectively bridge the differences
in communication style between nurses, physicians,
and others that result from the current educational
process.
i9 0 Leonard, Graham, Bonacum
www.qshc.com
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