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FALL 2005
FALL 2005
S Page 6 Patient Safety Awards Reminder
A QUARTERLY NEWSLETTER TO ASSIST THE MILITARY HEALTH SYSTEM IMPROVE PATIENT SAFETY
T
he Joint Commission on the Accred-
itation of Healthcare Organizations
(JCAHO) reviews and enhances its
set of National Patient Safety Goals annual-
ly. First published in 2003, the goals are pri-
marily based on information derived from
the JCAHO Sentinel Event database. Their
purpose is to promote specific improve-
ments in patient safety by highlighting
problematic areas in health care, describing
evidence and expert-based solutions to
these problems, and evaluating accredited
organizations for continuous compliance
with the specific requirements associated
with each Goal.
The DoD Patient Safety Program is
committed to assisting providers as they
adapt their practices to implement the
requirements of the Patient Safety Goals.
The Toolkit and practice suggestions Sample slide from Handoff Toolkit Power Point presentation, illustrating the
information foundation for the “I PASS THE BATON” mnemonic.
described in this article have been devel-
oped specifically to provide DoD facilities
with background information and practi- HEALTHCARE COMMUNICATIONS training, and, in fact, the handoff is a famil-
cal guidance related to JCAHO Safety DURING TRANSITIONS OF CARE iar tool, utilized to improve communication
Goals 2E and 8A/B. In January 2006, and teamwork behavior. New JCAHO
accredited organizations must comply with The DoD Patient Safety Program (PSP) requirement 2E, which mandates a stan-
new implementation expectations for these has provided robust training in healthcare dardized approach to handoff communica-
goals. The Handoff Toolkit will be accessi- team coordination from its earliest days. As tions, shines a spotlight on this teamwork
ble on the DoD Patient Safety Website the PSP has matured, so has its team train- element, creating the opportunity to inte-
(https://patientsafety.satx.disa.mil) on ing curriculum, now known as TEAM- grate this existing team strategy across the
December 1st, and is recommended as a STEPPS, administered by the DoD Health spectrum of healthcare practice.
helpful template for Military Treatment Care Team Coordination Program. Strate- In elevating the handoff to the level of a
Facilities as they review their individual gies for effective handoff communications National Patient Safety Goal requirement,
procedures for handoff communications. have been an integral part of TEAMSTEPPS Continued on Page 2
Patient Safety
Program Tools
Continued from Page 1
JCAHO explains that “…the primary objec-
tive of a “hand off ” is to provide accurate
information about a patient’s/client’s/resi-
dent’s care, treatment and services, current
condition and any recent or anticipated
changes. The information communicated
during a hand off must be accurate...”
JCAHO’s implementation expectations for
effective handoff communications are that
handoffs be interactive communications that
include up-to-date information, and require
a process for verification of the received
information. Interruptions during handoffs
are to be limited, and the receiver of the
handoff information should have an oppor-
tunity to review relevant patient/client/resi-
dent historical data.
The Toolkit developed by the PSP Health
Care Team Coordination Program builds on
the knowledge base underlying existing team
training and TEAMSTEPPS in particular. It Sample slide from Handoff Toolkit Power Point presentation suggesting the NEXT STEPS
for MTFs in implementing Handoff initiatives.
begins with the JCAHO requirements, but
seeks to provide a fuller understanding of the prompts providers to share information within DoD facilities. As an acknowledged
components of effective information trans- more efficiently and effectively among all lev- leader in the field of teamwork training, the
fer. Users will find a thorough review of gen- els of professional expertise, making explicit DoD Health Care Team Coordination Pro-
eral industry and specific healthcare research the communication of information that has gram, with your help, is in a unique position
in the area. Lessons learned from experience often been lost during handoffs. to make a real contribution to our patients
in emergency departments, intensive care The Toolkit concludes with a set of rec- and providers alike by integrating teamwork
units and operating rooms are noted. A con- ommendations for each facility to consider as and communication and creating a model
sistent dilemma described in all settings is the it establishes its individual handoff program. handoff process.
challenge of balancing the need for efficiency From leadership support to program design
with the need for effectiveness in handoff to preferred tools, the recommendations MEDICATION RECONCILIATION PRACTICE
communications. Passing too little informa- cover the critical elements of the optimal SUGGESTIONS
tion increases the potential for errors; requir- healthcare handoff. Rather than prescribe one
ing too much information creates a burden- standardized approach, the Toolkit provides a The Center for Education and Research in
some process that may be ignored in the press full range of information designed to explain Patient Safety (CERPS) at USUHS has assist-
of day-to-day practice. and facilitate well-structured handoffs, which ed in developing a compendium of informa-
One goal of the Toolkit is to assist can be adapted to the diverse cultures of the tion, research and practice guidelines to assist
providers find a balanced process for hand- DoD medical community. Included in the MTFs develop a systematic process for recon-
offs across the continuum of care. To that Toolkit for use by facilities are an extensive ciling medications. This effort is a direct
end, five current strategies are discussed: the bibliography and list of relevant resources, response to JCAHO National Patient Safety
I-SBAR, Expanded I-SBAR, FIVE-Ps, Data helpful illustrations, Frequently Asked Ques- Goal 8, which requires that health care organ-
TRIANGLE and the I PASS THE BATON tions related to handoffs and TEAMSTEPPS, izations “accurately and completely reconcile
mnemonic. Each option is analyzed in the and a supporting Power Point presentation. medications across the continuum of care”,
context of human factors knowledge, medical Dr. John S. Webster, a member of the effective January 1, 2006. It builds on the
errors commonly seen during healthcare DoD Health Care Team Coordination Pro- proactive initiative introduced at the National
transitions, the complexities of the healthcare gram, believes this coordinated effort to Naval Medical Center (NNMC) Bethesda,
process, JCAHO mandates and the need to structure handoff communications provides where staff developed a workable, repeatable
balance effectiveness with efficiency. The I an opportunity for significant improvement management response to medication recon-
PASS THE BATON mnemonic, which stands in patient safety. Each Service will oversee ciliation using the existing capabilities of the
for Introduction, Patient, Assessment, Situa- implementation of the handoff initiatives Composite Health Care System (CHCS).
tion, Safety Concerns, Background, Actions, within its facilities. Feedback from healthcare In establishing medication reconciliation
Timing, Ownership and Next Steps, is recom- providers will be solicited and incorporated as a safety goal, JCAHO recognizes evidence
mended as the most intuitive, flexible strate- into the Toolkit, which will be reviewed and from numerous studies which documents a
gy in current use. I PASS THE BATON adjusted to reflect emerging best practices Continued on Page 8
R
ecognizing the importance of the new munications. tions can be particularly problematic. Have
JCAHO 2006 Patient Safety Goal # 2E, the patient record and any diagnostic exams
which requires the implementation of Clinical test orders and results present during all consults, rather than rely-
a standardized approach to handoff commu- Commonly part of the information ing on a verbal description. Consult physi-
nication, the DoD Patient Safety Center has handed off, orders and/or results may not be cian should initial diagnostic reports and
reviewed relevant literature and information known or documented at the time of the write a brief initial note, followed by a longer
received from our Military Treatment Cen- handoff. Consider these improvements: report.
ters (MTFs). While the definition of a hand- Include a laboratory flow sheet in the Provider-provider communication
off — the transfer of information between medical record to document the tests should explicitly establish who has primary
health care providers — seems easy to ordered, with order dates, test results, and responsibility and agree on a clear line of
understand, experience shows that achieving dates results are received. responsibility for follow-up to prevent mis-
an effective and efficient transfer continues Have technicians review the laborato- understanding.3
to challenge busy caregivers. ry flow sheet when preparing the record for
As you exchange information about your a patient’s appointment; print any labs/test Documentation
patients, keep in mind that the primary results that are not recorded; give test results Documentation should be reviewed
objective of a handoff is to provide accurate to the provider to review and record during prior to, or at time of, handoff:
information about a patient’s /client’s /resi- the patient’s appointment. Medical staff should clarify critical
dent’s care, treatment, services, current con- Have providers review the lab flow information (e.g. patient situation, safety
dition and any recent or anticipated change. sheet at each visit and retrieve, record or concerns, background, planned actions and
JCAHO’s implementation expectations order outstanding labs/test results. their timing, and those responsible for
require up to date information, interactive Document verification of verbal com- patient care) in the medical record or the
communication, limited interruptions dur- munication of laboratory results in the med- appropriate transfer document. “I PASS THE
ing handoffs, a process for verification of the ical record at the time the information is BATON”, a mnemonic recommended in the
received information and the opportunity by communicated. Toolkit, will assist this process.
the receiver of the handoff information to Have health care providers identify a Log books or spreadsheets should be
review patient /client/resident historical surrogate to review test results in their managed by centralized personnel within a
data.1 absence. clinic or ward to track tests and their results. 4
In DoD practice, as is true across the Hand-carry reports of incomplete and Utilize a white board or computer for
larger healthcare system, handoffs are com- abnormal tests to the provider or surrogate; the most recent vital sign and test results
mon in the emergency room and clinic set- enter results of incomplete or abnormal tests during shift reports. Update all patient infor-
ting when multiple providers treat the into a database and review each month. Ver- mation prior to the report and highlight any
patient, during change of shift or personnel ify provider contact with the patient con- areas of concern that should be addressed.
and when a specialist or consultant is need- cerning abnormal results.
ed. Providers rarely have complete medical Involve patients in their care. Ensure 1
Joint Commission 2006 National Patient
record information when the patient that they understand what tests are ordered Safety Goals Implementation Expectations,
receives care in multiple settings. Often, and when they should receive results, thus accessed 9/22/05, http://www.jcaho.org/ac
patients are sent to facilities where the pre- adding additional checkpoints to the test fol- credited+organizations/patient+safety/06_nps
vious medical records are not available. In low-up process.3 g_ie.pdf
23
the acute care setting the exchange of infor- Shepard, A; Kostopoulou, O. Fragmenta-
mation frequently occurs at change of shift Consultations between providers tion in Care and Potential for Human Error,
or change of coverage, commonly with The exchange of information among accessed 9/22/05, http://www.dcs.gla.ac.uk/~
reports which are mostly verbal, and may be consulting providers can be either verbal or johnson/papers/HECS_99/Sheppard_Kostopou
ambiguous. Some handovers are done from written, but special care must be taken to lou.htm
memory with no documentation.2 Impor- ensure that it is complete, accurate and up to 4
Gandhi, T. K. Commentary: Fumbled
tant information often is not conveyed date. These actions will improve this process: Handoff: One Dropped Ball after Another, ANN
because it has not been included in the Provider requesting a consult provides Intern Med. 2005; 142:352-358
F
ailure to remove surgical instruments at sponge and instrument counts probably
the end of a surgical procedure may be works well, but there is no evidence to The law only requires that foreign bodies not
a more common occurrence than sus- describe the actual failure rate. What little be negligently left in patients.”13 The Associ-
pected. A recent study reports that this may evidence exists suggests that system failures ation of Operating Room Nurses (AORN)
occur in as many as 1 out of every 100 cases are the result of human related factors (i.e., has published accounting guidelines for
to as few as 1 out of every 5000 surgical cases, the count is not performed, or is ignored), instruments used during surgical proce-
with associated mortality ranging from 11 to and that ancillary methods such as x-rays are dures. The following practices were devel-
35%.1 also fallible. The authors conclude that the oped by the AORN Recommended Practices
The process by which counts are per- industry is left with a paucity of data regard- Committee and became effective January 1,
formed is not standardized. Individual hospi- ing the prevalence of this error and the effec- 2000.
tal policies vary widely, relative to their surgi- tiveness of preventative measures.6 “Sponges should be counted on all proce-
cal sponge/sharps/instrument counting pro- A recent study by Gawande, et al, consid- dures in which the possibility exists that a
cedures. The Joint Commission on the ered the risk factors for retained instruments sponge can be retained. Sponge counts
Accreditation of Hospitals (JCAHO) does and sponges after surgery.7 They conclude should be taken:
not dictate that counts must be conducted that “studies of error to date have generally 1. Before the procedure to establish a base-
nor does it prescribe how counts should be measured only the frequency of the outcomes line.
conducted in the facilities that perform them. of specific types of errors, not the roles of 2. Before closure of a cavity.
Historically, the JCAHO sentinel event policy particular contributing factors.”8 Their 3. Before wound closure begins.
has specifically stated that “unintentionally research team used a retrospective case-con- 4. At skin closure or end of the procedure.
retained foreign body without major perma- trol design involving the records of medical 5. At the time of permanent relief of either
nent loss of function” does not require malpractice claims and incidence reports. the scrub person or the circulatory
reporting.2 In June 2005, JCAHO revised the Additionally, members of operative teams nurse.”14
list of reviewable sentinel events to include were interviewed. In this study, 54 cases The purpose of these prudent patient
the unintended retention of a foreign object involving 61 events were reviewed (69% safety measures is to ensure that discrepan-
in an individual after surgery or other proce- sponges and 31% instruments).9 cies at any stage of the surgery will require the
dure.3 According to Gawande, et al, cases involv- team to do a repeat count. If the discrepancy
According to Gibbs et al., the prevalence ing the retention of a foreign body after sur- persists, then appropriate steps will be taken
and severity of this target problem is gery significantly increased in emergencies, to locate any unaccounted items.
unknown, and without accurate information, unplanned changes in procedures, and with Retained sponges and instruments con-
the true magnitude of the opportunity for individuals having a higher body-mass tinue to be a disturbingly repetitive problem.
impact is unclear.4 index.10 The group’s findings support the Verna Gibbs, MD, of the University of Cali-
The Kaiser, et al, study reviewed 67 med- confirmation that leaving behind foreign fornia at San Francisco notes a continuing
ical malpractice claims involving retained bodies in a patient after surgery is an uncom- mantra that “current preventative practices
foreign bodies.5 The study notes: mon but dangerous error. They note the fol- fail due to human related factors. Surgeons
1. 55% of retained sponges were found lowing sequelae: use nonradiographically detectable sponges,
after abdominal surgery, 16% after vaginal In one case, the retained object result- counts are not performed, and when they are
surgery. Falsely correct sponge counts can be ed in death. performed and errors occur, backup detec-
attributed to: In 22% of the cases, the retained for- tion systems are not systematically
Team fatigue eign bodies resulted in small-bowel fistulae, employed.”15
Difficult operations obstruction, or visceral perforations. JCAHO now requires this event to be
Sponges “sticking together” 69% of the patients required re-opera- reported regardless of the patient outcome.
Poor counting system tion for removal of the object and manage- Collection of this data will assist the industry
2. In cases involving retained sponges, the ment of the complication. accurately quantify the prevalence of this
sponge count had been falsely reported in The foreign body in the remaining event type. Through qualitative analysis of
76% of non-vaginal surgeries; in 10% of the patients the data and methodical human factor
cases no sponge count had been conducted. - was expelled, assessment, guidelines and tools can be
Incorrect sponge counts that were accepted - could be removed at the bedside, developed for surgical teams and their facili-
prior to closure resulted from: - was discovered incidentally and ties to implement. This process change will
Surgeon dismissing an incorrect count removed at the time of another operation. enable the team to no longer ask the question
without re-exploring the wound. The majority of surgeons and nurses typ- “was the count correct” but to ask and accu-
Nursing staff allowing an incorrect ically rely on the practice of counting the rately determine “is there a sponge or instru-
count to be accepted. sponges, sharps, and instruments as a means ment in the patient?” before finally closing
In 3 of 29 cases in which inter-opera- of eliminating the possibility of retained for- the surgical site.
Never cut sponges. Each sponge used should have an x-ray Count at start of procedure, after each cavity is closed, at Get repeat films and over penetrated films as needed. (This
detectable strip. skin closure, and following any change in staff. may help in identification of items located behind dense
organs.)
Do not prop up internal organs with surgical towels. Make sure any x-rays ordered are documented and co- Call all “significant” findings directly to the attending sur-
signed, films are sent promptly for a STAT interpretation geon.
by the radiologist, and that the indication for why the film
is being done (such as to rule out a retained sponge or
needle) is made known to the radiologist.
Ensure counts are done on all items. Check kick-buckets and trash cans before initiating Requests for stat X-rays in the OR for surgical cases with an
sponge and instrument counts.17 incorrect count should include:
• Type of procedure;
• Surgical site;
• Surgeon, and
• Nature of missing item.
Stat intra-operative X-rays should be jointly or sequentially
reviewed and discussed by the surgeon and the radiologist.17
Inform circulating nurse when you pack a wound, with what item, Enforce quiet or dedicated time during the final counts so Recognition of retained bodies after surgical procedures
and how many items are used. nurses performing them are not disturbed.17 should be an integral part of residency training in radiology.17
Request count with any change of staff. Conduct observational study of count process to learn Ensure that portable X-ray machines can provide adequate
vulnerabilities, identify specific distractions, and improve imaging data to meet the needs for assisting with identifica-
process design.17 tion of retained items.17
Ensure count is done at start of case, after leaving each cavity, Maintain continuity whenever possible by having the
and upon skin closure. Remember you may need to tell the nurse same team or OR staff start and complete a case. When-
you need to do a count (he/she may not know, for example, that ever possible, lengthen assignments for consistency.17
you are leaving a cavity).
If the post-procedure count is off, then: Annually, assess staff competencies on the management
• Make a visual inspection of the operative area. of sharps instruments, and sponges.17
• Do a manual search of the operative area.
• Obtain x-ray and have it read STAT by the radiologist.
• Make sure the x-ray taken includes all the operative fields in
question.
• Document all measures taken.
The practitioner who orders the x-ray must follow up and read
both the body and conclusion of the official radiology report. This
is in addition to any verbal reports taken over the phone or in per-
son.
T
he third annual DoD Patient Safety Training. To be eligible for an award, a Package, containing a project timeline and
Awards will be presented at the project or initiative must demonstrate templates for use, can be downloaded from
2006 TRICARE Conference in Jan- that it has been tested and proven to the site. A review of the projects awarded
uary. MTFs are encouraged to submit reduce errors, improve patient safety and recognition in the past can be found in the
projects for consideration by November outcomes. Projects must be data driven, 2004 and 2005 Winter Newsletters, which
30, 2005. Award recipients will be notified practical, creative and transferable across are archived and accessible on the website.