Nuts!

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!)

STLs happen

Acting on an urge to find an outdoor spot to enjoy a warm spring evening, my husband and I recently found ourselves perched on a deck three stories above an old tavern, giving us a bird's eye view of the old courthouse in the small southern city where Larry Flynt, the publisher of Hustler magazine, was gunned down in 1978. I didn't know this fact, although I've lived in nearby communities for over two decades, but my husband did. This Trivial Pursuit-worthy fact, coupled with an old red pick-up truck that was missing the entire driver's side door (but, happily, not the driver) occupied our conversation until I remembered we were right down the street from the new courthouse (where I had been a jury member when a fellow citizen sued the Troy-Bilt company following a chipper-shredder mishap in the mid-1990's). We were destined for good conversation.

• Targeting, then deliberately shooting, a fellow citizen with a handgun
• Driving a motor vehicle absent a key piece of personal protective equipment
• Getting your hand stuck in the business end of lawn and garden equipment

These are three very distinct ways to screw up. (Normally, I'd use the term err--as in To Err is Human--but, hey, it was Friday night.) My husband, of course, would have preferred to continue talking about Larry Flynt, Hustler, or the guy in the truck without the door. But I was determined to talk human factors engineering, the study of how people, given our capabilities and limitations, can be predicted to perform tasks that involve using machines under real world conditions.

"Did you know," I asked, "that the probability of a well-trained, motivated, competent person producing an error while performing a routine task is 1 in 2000?"

Erring while doing something you know how to do is a mistake characterized as a slip, trip, or lapse (STL), and STLs are the most common of human errors. Bringing home Coke instead of Diet Coke or Fruit Punch Juicy Juice instead of Cherry Juicy Juice are classic STLs. Environmental factors, such as similiar packaging, product placement on the shelf, lighting in the grocery store, and distractions during the selection process play a role in STLs. Irrespective of intention, STLs happen, and they happen most often to seasoned people performing tasks and activities they are normally adept at doing. If it happens in the grocery store, it can happen at work.

The chipper-shredder mishap I heard during my jury service could be characterized as a slip, trip, or lapse. (The gentleman who brought the suit was raised on a farm and had used heavy equipment since the time he was a young child.) When an experienced, but busy or distracted, nurse attaches a syringe containing viscous liquid, meant for oral administration, to an IV line and inadvertently administers it intravenously, you've heard another account of a slip, trip, or lapse.

I still haven't gotten over the fact that I learned about slips, trips, and lapses while serving on a jury, instead of during the course of my professional training ten years earlier. How helpful it would have been to know that systems could be designed and engineered in order to compensate for mistakes competent professionals can be predicted to make. (At the risk of beginning a rant, let me point out that in the U.S., we landed a man on the moon three decades before oral syringes--devices that are incompatible with IV tubing and thus prevent competent people from having a 1-in-2000 slip that can kill a person they're trying to cure--became commercially available in hospitals.)

I write about medication safety over at Medscape, on a popular blog called On Your Meds. This forum draws tons of comments from front line clinicians. Most use it to talk about what's it like to use existing processes to deliver the meds (and the care) they want to give. A few weeks ago, On Your Meds received over 8,000 hits in the first 24 hours after a piece entitled, "Medication Misadventures" was posted.

If you're a front line clinician, I encourage you to check out the hundred or so comments in response to "Medication Misadventures," reflecting about the safety problems others perceive, how your system benchmarks with others, and how well you (and your patients) are protected from predictable slips, trips, and lapses.

If you coach, lead, or manage front line clinicians or have a role in funding the systems (equipment, software, and the support services needed to fully operationalize them), I encourage you to read the comments left in response to "Medication Misadventures." Comments are simply electronic footprints, showing clinicians' perceptions about the fitness of the medication use system. These are people (your people, perhaps) interacting with machines under real world conditions. How well is your medication use system engineered to account for human factors?

If you sell medication safety, remember to talk about human factors when you come calling. We're not shooting our fellow citizens with a hand gun. But we may be tempted to drive an old pick-up, and we regularly have to dislodge pieces of cat brier from the chipper-shredders we use to get the job done.

And if you design equipment or systems that will make the medication use system safer, please get back to work. We need you.

Off to mulch..... stay safe and come back soon!