Saturday, May 2, 2009


Peter Pronovost may think we're nuts. Actually, he said doctors and nurses work in a system that's nuts. But, I'll toss off the virtual nurse's cap this morning, and offer the same advice I'd give to my kids: Nutty is as nutty does.

Pronovost, a well-respected patient safety advocate and practicing clinician, appeared in a Wall Street Journal blog post a few weeks ago, sharing his views about safety gains that could arise from hospital-industry-regulatory collaboration modeled on aviation partnerships. Advocating for measures that transcend what professionals closest to the secretions can pull out of their, well, shall we say, personal supply cabinets, Pronovost pointed out that clinicians who work in hospitals need better and more effective tools to prevent mishaps.

If an infusion meant to be delivered to the epidural space can kill a person if it's inadvertently infused intravenously (as has tragically occurred many times in the past), safest practice would be to make epidural tubing incompatible with the cousin ports populating the patient's nearby IV tubing. An engineered device constraint is far more likely to prevent patient harm than reminding clinicians who manipulate the lines to "be more careful" and placing labels on tubes and lines. Especially when the therapeutic care environment looks like this:

photo used with permission

Personal diligence and adjuvant labeling shouldn't be abandoned, but a constraint like incompatible tubing is a far more effective way to derail a significant error that has been set in motion.
If you've been following Flo's posts for the real-time patient safety lessons she offers, it's worth reviewing the medication use process, recalling that the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient.

Slide based on modeling described by James Reason

Tubing misconnections are errors that originate downstream, in the administration node, meaning there are limited opportunities to uncover them and prevent harm before they reach a patient. Engineered incompatibilities between epidural and intravenous line ports and connectors are powerful constraints, one of the few reliable ways to catch wrong-route errors arising from a clinician's slip, trip, or lapse at the point of medication administration.

When cross-functional stakeholders join forces in healthcare, as they have in aviation, your patients may be as safe while giving birth in the U.S. as they are while flying commercial.

This is not what I envisioned when I became an intrapartum nurse some years ago, but apparently what I should have been saying all along is, "I'm the SafetyNurse, fly me!" (My husband says I've been cleared for take-off, but he may be saying something unrelated to this topic. In any event, I hope you'll travel safely!)

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