Tuesday, April 14, 2009

Grand Rounds

Grand Rounds is up at Pharmamotion with an interesting series of posts about the state of health and healthcare. Anyone looking for exemplars or barriers to the Institute of Medicine's six dimensions of care (Safe, Effective, Timely, Efficient, Patient Centered, and Equitable) will find interesting things to read there today.

I'm reflecting on Nurse Ausmed's post that was included in Grand Rounds because it speaks to realities of the system front line clinicians rely on. In this post, a seasoned nurse reflects on the theme of nursing advocacy, an important component of nursing care. The touching account of how she helps young brothers prepare for the death of their newborn sibling shows the value of individualizing care, of using "teachable moments" that unfold at the bedside, of responding in ways that set the stage for healing that will occur long after clinical care ends. This is the essence of patient and family centered care.

Nurse Ausmed also shares how nurses' advocacy can make medication administration safer. It certainly did in the case she described (having the concentration of an infrequently used medication infusion--being administered to a pediatric patient--changed so that titration in mg/kg/hr would require fewer calculations at the bedside). By recognizing and responding to an error-prone condition, Nurse Ausmed makes a potential mistake that had been set in motion visible, and advocates effectively to mitigate the error-prone condition before harm occurs.

Now let me exchange my virtual nurse's cap for a safety engineer's hard hat and invite you to put one on, too. If you're new to systems thinking, and you want to learn how to analyze the error-prone conditions in your workplace, here's a real-time exercise:
  • Re-read the portion of Nurse Ausmed's post entitled, "Simplify, Simplify." (She's provided a significant risk-reduction hint in the title.)

  • Ask yourself: Could this error-prone condition have been identified and lessened before it hit the front line? Nurse Ausmed's efforts were stellar. She's clearly an A player (and she's at the beginning of her shift!). But I'd encourage you to identify upstream interventions--those that could reasonably be undertaken through science-based, interdisciplinary collaboration--that could have lessened the likelihood of error before the infusion reached the patient.

  • Check back on Thursday to see how my analysis aligns with yours.

To help you get started, here are links to a few resources I'm going to use: James Reason's modeling of human error; ISMP's analysis of the events that led to the death of Sebastian Ferrero; cues and clues offered in The Joint Commission's Sentinel Event Alert related to pediatric medication safety; and recommendations from a multi-stakeholder group of experts convened last summer to identify ways to prevent IV medication errors.

Enjoy Grand Rounds this week, and check back here on Thursday to see principles of error-reduction at work!

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