Thanks for speaking up

When I give talks about patient safety, I usually include a slide called, "Why Pilots Won't Nurse." It's an attention getter, one that draws smiles and sometimes fosters an "a-ha" moment for students, seasoned clinicians, and administrators.

I think that pilots won't nurse because, as a group, pilots are knowledgeble enough to reject systems that lack sufficient barriers, redundancies, and opportunities to uncover and rectify potentially lethal errors that have been set in motion. Commericial aviation isn't fool-proof, but the industry's 1 in 6 million crash rate shows what can be accomplished in high stakes domains when adequate barriers, redundancies, and recovery ops are in place.

I could add another slide: why pilots don't practice pharmacy. And there's no better place to read why than Bob Wachter's thanksgiving day post about the tragic case in Ohio, one in which a little girl lost her life, a family dissolved, and a pharmacist went to jail. 

Late last summer, Mike Cohen, the president of the Institute for Safe Medication Practices, published An Injustice Has Been Done about what happened to pharmacist Eric Cropp in the aftermath of little Emily Jerry's death. Bob and Mike talked about what Eric's case means, for professionals and for patient safety in a CareFusion webinar (the recording is available here). Thanks for speaking up.

Don't throw a skater under the Zamboni when you're already on thin ice

I spent a few days last week with my friend and mentor, Mike Cohen, the President of the Institute for Safe Medication Practices. Although Mike has a goodly number of titles and highly recognizable accomplishments (like being named a MacArthur fellow in 2005), you might enjoy spending time with him for the same reason I do: He's a mensch.

When Mike worked as a clinical pharmacist in a hospital pharmacy over three decades ago, he observed how frequently flaws in the system used to deliver medications set professionals up for failure. Systems engineers use terms like "single fault failures" and "opportunities for recovery" when they design work processes that reliably produce an intended outcome. But it's easier to think about these concepts using things we know from our own experiences.

Let's say we send a group of ice skaters onto a frozen pond. Some skaters in the group are Olympians, some grew up on a lake in Moose Jaw, Saskatchewan, and some are promising beginners. Everyone who skates on your pond knows how to lace up and is able to remain vertical while on the ice. They look good and on days when the ice is frozen solid, all skaters skate safely.

But your ice is not uniform. When the temperature climbs, the ice becomes thin. Dangerous spots are not marked. The skaters from Moose Jaw are better able to spot unsafe ice. They stay off or take action to avoid the risky patches. Statistically, Moose Jaw natives fall through less often than the Olympians and the beginners. But at times, even the Moose Jaw skaters go through the ice.

Variability is the enemy of people interested in engineering safety. Variable conditions make it tougher for beginners to navigate a high stakes process safely. When one of your lighter weight Olympians glides over a thin spot without falling through, beginners erroneously believe the ice is safer than it really is. Variability will trip up seasoned people, too. And when no one has gone through for awhile, it's easy to forget how important it is to mark the weak spots and have a means to pull someone out when the ice cracks.

The medication use system is built on thin ice. It was in the 1970's when Mike Cohen first began imploring healthcare providers to look beyond the characteristics of the last skater who crashed through and it remains thin today.

Here's the evidence: Since 2004, Pennsylvania has required healthcare facilities to report serious adverse, unintended medical events and near-misses to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This reporting occurs irrespective of whether patient harm occurs. Last month, PA-PSRS logged its one millionth report. Over 25% of these events involve medications.

You should infer that similar data could be culled from the state where you live. Remember that, like the people in Pennsylvania, you'll have beginners, Olympians, and Moose Jaw natives on your pond. Ask what measures are in place to ensure the ice is being shored up and the thin spots marked. And you should be interested in ice conditions whether you are a patient or a professional.

In hospitals, things that shore up medication safety fall into broad categories that are objective and observable. In fact, ISMP makes a series of comprehensive medication safety self-assessment tools available for free download on their website. Using these tools, organizations can measure their progress in making medication delivery safer over time.

You should be interested in what happens to skaters who fall, too. At about the same time that Pennsylvania passed the one million mark after five years of error reporting, the citizens of Ohio sent a pharmacist to jail for an inadvertent on-the-job error, one that led to the tragic death of a toddler.

Mike Cohen has published a detailed piece An Injustice Has Been Done that explains how thin the ice in the Ohio case was. It's an impassioned plea about the dangers of punishing people whose primary fault arises from being a fallible human.

In the past five years, Pennsylvania has had 1,000,0000 events reported, each an opportunity to identify a variable that affects the quality of the ice and improve it before harm occurs. (Only 4% of the Pennsylvania reports involve patient harm.) If skaters who stumble know they will be pushed the rest of the way down, who will make a choice to share details about what undermined their performance?

And down the road, when your team can no longer recruit Olympians and Moose Jaw natives, you'll be crossing increasingly thin ice. You won't need particularly sharp blades to push the beginners under.

First responder at 35,000 feet: The value of a good book

A few years back, I took a flight to Philadelphia to interview for the Safe Medication Management fellowship at the Institute for Safe Medication Practices. I was using the travel time to skim through "Medication Errors" (2nd edition), a book written by people I would meet the next day. Seated in an aisle seat, I had the iPod going full tilt, a distraction that both blocked airplane sounds and helped settle the butterflies in my stomach.

I may have been aware of some peripheral commotion but didn't really pay attention until a flight attendant, who had apparently noticed the title of the large textbook on my tray table, tapped me and asked, "Are you a medical professional? There's a gentleman on the plane who thinks he may be having a stroke. Are you willing to help him?"

I'm a perinatal nurse. Placentas. Labor. Birth. High-stakes vascular events in my clinical world are nearly always preceded by the diagnosis "pre-eclampsia," something a male simply cannot get. "Sure," I said, struggling to put on my shoes. "Stroke, stroke," I thought as I lumbered toward the designated seat. I think I should say something like, "What makes you think you are having a stroke, sir? Does something feel numb? Are you having trouble moving?"

When I reached the gentleman, however, talking was out of the question. He was cold, clammy, unresponsive, with a thready, bradycardic pulse. Where I live, people call this condition, "fixin' to die."

The flight attendants, working from a checklist, had notified the captain and sought help from medical personnel amongst the passengers. Communication with medical experts on the ground were being facilitated (loudly, with assessments and observations called from one flight attendant, stationed near our passenger-turned-patient, to another flight attendant, stationed at the now-open cock-pit door).

We apply oxygen by tight face mask. The first responders are three: me, an ex-Army corpsman, and someone who declines to be identified, although he is able to get oxygen flowing. (Something that's useful to know if you're a first responder while in flight: they don't drop the oxygen from the over-seat compartments. That's for emergencies that impact the oxygenation of everyone on the plane. Your team will be given a portable oxygen tank, and it may be helpful to remember "lefty-loosey, right-tighty" once you locate the on-off valve.)

"I have an AED, ma'am, I have an AED," the flight attendant repeated, rather persistently, pushing the box in my direction. Still feeling a pulse, but he's grayer, and the pulse rate is lowering. "Think, think," I thought. (The image of defibrillating a large man, mid-cabin just couldn't take hold in my mind. All I could picture was the impossibility of saying, "I'm clear, you're clear, we're all clear," when 5 rows of passengers are sitting in the metal chairs this man is going to touch if we lay him out here.)

Meanwhile, there's more flight attendant-to-cockpit communication (okay, yelling) as preparations for flight diversion are considered in light of the passenger's grave condition. "Does he have any medical conditions? Heart disease, diabetes,....." came the question as the flight attendant moved down the checklist. His traveling companion looks up, gasps, and says, "He has diabetes." Sweeter words had never been heard. This was something a perinatal nurse could do something with.

"Sugar," I said to the flight attendant. "Bring me sugar from your cart." The gentleman was unresponsive but the table sugar, which I applied (er, jammed) rather unceremoniously under his tongue and moistened with a few drops of water made him come around right quick. (Something else that's helpful to know if you're a mid-flight first responder is that flight attendants have a checklist and their efforts work in tandem with any assistance you can offer. The checklist helped to get useful facts, like this gentleman's diabetes, uncovered rapidly. This information would have been used by the medical professionals on the ground if I hadn't been able to put the pieces together and initiate corrective action. The take-away lesson? Help may not be as far away as it initially feels at 35,000 feet.)

It turned out that the passenger was a relatively new diabetic, and the day of traveling had put him off of his normal eating routine (although he had remembered to take his medications that morning). We continued on to Philly, with the gentleman refusing the EMS care that met him at the gate. I waved to him at the baggage claim area, and told his companions that he really should seek follow-up care immediately, something I very much doubt he did.

At my interview at ISMP the next day, I was asked if I had had a good flight. Of course, I told the story about the book and the in-flight interventions, at which point one of the staff members said to Mike Cohen, ISMP's president, now my mentor and friend, "See Mike, the book saved another life." Probably true. (I learned a great deal of life-saving information when I actually read the book, and I highly endorse it, both for its intended purpose and any adjunct benefit it affords the traveling public.)

May you always have a good book and fly the friendly skies!

Materials in this post first appeared on my Medscape blog, "On Your Meds: Straight Talk about Medication Safety" in April 2009.

Medication safety: It's hard to be (a) patient!

Patients for a Moment is a new blogging round-up, one that collects stories from patients and people interested in the experiences of patients. I joined in this week and shared a short piece about what safer prescribing would look like. There's a lot going on with medication safety in other venues as well. The FDA just heard recommendations from an advisory panel, and it's looking like consumers are going to get some help in managing risks associated with acetaminophen.

A few weeks ago, I listened to an excellent webcast about medication management and safety aimed at health care professionals (click here to go to the link to hear the re-broadcast). In the U.S., approximately 25% of all reported medical errors involve medications. The most important "take-away" I heard occurred when Peter Angood, a physician leader in the patient safety movement (someone intimately familiar with medication safety risk points), shared how his drug history had been botched during a recent outpatient procedure.

The communication infrastructure surrounding medication use is so poor that the system breaks down for patient safety experts with relatively uncomplicated medication profiles undergoing scheduled diagnostic procedures? Yes. Routinely. Bet on it. Good luck to the rest of us.

Dr. Angood's story serves as yet another "call to action" as people in the United States consider how to spend $20 billion dollars to make healthcare IT serve patients and providers in meaningful ways.

Here's the take-away for now: While we await better integration of electronic medication data, go ahead and establish an electronic medication record of your own. ISMP's Consumer Med Safety website, in conjunction with iGuard, offers a free MedSafetyAlert! service for listing and tracking your medications. It's easy to use, and iGuard's medication platform is being adopted by larger electronic medical record systems, meaning that the data you enter will likely "flow through" to more sophisticated e-health record keeping systems (maintained by you, your caregivers, or a healthcare facility).

Based on the information you enter into MedSafetyAlert!, you'll receive tailored alerts and monthly summaries via e-mail. I've used the service for several months, and found it to be simple, non-invasive, and easy-to-access.

LASA: It's Not Just Another Bad Abbreviation

I'm talking about errors associated with look-alike, sound-alike (LASA) drug names today because LASA problems offer concrete examples of risk points that dog clinicians involved in the medication use system. (For purposes of this discussion, my quick-and-dirty working definition of a risk point is "any underlying factor that predisposes to error.")

In the last post, I referred to new research confirming something you probably already know: healthcare professionals struggle with reporting mistakes, and we struggle with the fact that we are fallible when we're involved in errors. When people believe that “bad people” or “good people having a bad day” are individually responsible for most medical errors, it’s easy to see why reporting error and reconciling feelings of personal responsibility become burdensome. But reporting and reconciling become easier when you look for solutions that improve the nature of the process, not the nature of the people. Face it, we’re all going to have a bad day once in awhile, and, unfortunately, not all people are good.

(I recently spent a year as the Safe Medication Management fellow at the Institute for Safe Medication Practices. But, as you can read in my last post, I was tripped up by look-alike packaging of hand sanitizer and hand soap a few weeks back, proving yet again that “knowledge” does not trump “process.”)

Human error is typically a by-product of the systems we practice in, and with LASA errors, it’s hard to miss the risk points. The category of LASA-related errors exists because, frankly, drug names are often similar to one another. It's easy to see how words and phrases like "oxycodone and oxycontin" and "Novolog Mix 70/30 and Novolin 70/30" could be mixed up. Similarities like these regularly give rise to confusion, and yes, error. We see look-alike, sound-alike word confusion in other settings all the time: if you haven't seen "your" erroneously substituted for "you're" recently, you're reading better things than I am! But when word mix-ups have the potential to give rise to medication errors, stronger processes that guard against selecting the wrong one need to be in place.

Next time, I'll share data and some easy-to-access resources for preventing LASA errors. Maybe you have an example of a look-alike or sound-alike error to share? (If you do, tell your story in the “comments,” omitting identifying information. On Florence dot com we neither offer medical advice nor violate HIPAA regulations.)

So, good people, stay safe and come back soon!