Want to Prevent Errors? Kairol Has a Ribbon for You!

One of my favorite patient bloggers has a great post up today. Kairol Rosenthal at Everything Changes shares important things about what patients can do to help prevent medical error. Check out How Do You Prevent Errors in Your Care?

Campaigns that help patients become more active, more visible in their care are on the rise. The Joint Commission has one I like: Speak Up. The focus of campaigns like these--rightly, I think--is on behaviors patients and caregivers should engage in. But it's interesting to know the science behind the recommendations.

Patients are the last line of defense in a complex system of care. Ideally, errors are prevented (through strong system design and rigorous adherence to the processes designed to avert human error). But the next-best thing to preventing an error is to detect it and mitigate negative consequences before the error reaches and harms a patient. This is why the patient's (or advocate's) voice is so important. They are the last line of defense that can detect an error that's been set in motion. Knowing what to expect helps people recognize when things are not going as expected.

For example, asking "Did you wash your hands?" helps avert a common error of omission set in motion close to the patient. Errors arising close to the point of care are particularly hard to detect. (They stand in contrast to things like a physicians' prescribing error which--while potentially serious--routinely undergoes scrutiny by pharmacists and, in a hospital setting, nurses.) The likelihood of detecting and correcting an upstream error (like a wrong dose or wrong drug prescribing error) is good. The likelihood of detecting a downstream error (like failure to perform hand hygiene) is not.

Many clinicians are working to change cultural norms in their workplaces, things that discourage patients and professionals from speaking up when they have a concern about how care is unfolding.  It's a viable strategy that helps cure a healthcare epidemic.

Kairol thinks they should be wearing a ribbon.

Gifts that keep on giving

This week at Grand Rounds, DiabetesMine blogger Amy is celebrating her birthday with stories full of good things. Florence dot com is over there, misbehaving with a story about Ring Dings, a move that might end my short blogging career.

I really liked the post about banana-split jelly beans (and not just because Ring Ding jellybeans might help Paula Poundstone and Michael Pollan bridge the gap between food and edible food-like substances).

In the spirit of Amy's birthday, I'm posting links to things I think are worth passing along to your friends, family, and patients:

• AHRQ has a few 30 second public service announcements that are worth viewing (if they haven't already shown up at commercial breaks during Grey's Anatomy and House in your ad market). Seeing a healthcare provider like a waiter or a cell phone salesman may interfere with some healthcare mojo, but it's a necessary first step in getting people care they need and would actually like to have. I like the 3rd video in which healthcare workers burst into song to elicit questions from patients. (Even though the spot reminds me, somewhat uncomfortably, of the sign at my hairdressers' that says, "I'm a beautician, not a magician.") The AHRQ folks get an "A" for casting that one.


• The Institute for Safe Medication Practice's ConsumerMedSafety website has a handy link that allows consumers to log their medications, creating a readily accessible medication list sharable amongst all providers. The added benefit is that e-mail messages are provided to the consumer should a medication alert, recall, or potential interaction be identified. The service is offered in partnership with iGuard.

Enjoy these, and visit Amy's blog for links to more things that will inspire you to have a great day!

Coming Friday: Reducing risk with IV pediatric infusions. Read Part 1 and Part 2 and get ready to compare your analysis with mine!

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!