Consider three different scenarios that place healthcare patient safety at risk. The first is an individual hazard, the second human behavior, and the third a system issue in the broad sense of "system" as distinct from information technology (IT).
The first consists in placing concentrated potassium alongside diluted solutions of potassium based electrolytes. Now you need to know that intravenous administration of the former (concentrated potassium) results in stopping the heart almost instantaneously. In one tragic case, for example, an individual provider mistakenly selected a vial of potassium chloride instead of furosemide, both of which were kept on nearby shelves just above the floor. A mental slip-erroneous association of potassium on the label with the potassium-excreting diuretic-likely resulted in the failure to recognize the error until she went back to the pharmacy to document removal of the drug. By then it was too late.
Second, a pharmacist supervising a technician, working under stress and
tight time deadlines due to short staffing, does not notice that the sodium
chloride in a chemotherapy solution is not .9% as it should be but is over 23%. After
being administered, the patient, a child, experiences a sever headache and
thirst, lapses into a coma, and dies. This results in legislation in the state
Finally, in a patient quality assurance session, the psychiatric residents on call at a major urban teaching hospital dedicated to community service express concern that patients are being forwarded to the psychiatric ward without proper medical (physical) screening. People with psychiatric symptoms can be sick too with life-threatening physical disorders. In most cases, it was 3 AM and the attending physician was either not responsive or dismissive of the issue. In one instance, the patient had a heart rate of 25 (where 80+ would be expected) and a Code had to be declared. The nurses on the psychiatric unit were not allowed to push a mainline insertion into the artery to administer the atropine and the harried resident had to perform the procedure himself. Fortunately, this individual knew what he way doing and likely saved a life. In another case, the patient was delirious and routine neurological exam - made up on the psychiatric unit, not in the emergency room where it ought to have been done - resulted in his being rushed into the operating room to save his life.
In all three cases, training is more than adequate. The delivery of additional training would not have made a difference. The individual knew concentrated potassium was toxic but grabbed the wrong container, the pharmacist knew the proper mixture, and the emergency room knew how to conduct basic physical(neurological) exams for medical well being. What then is the recommendation?
One timely suggestion is to manage quality and extreme complexity by means of check lists. A checklist of high alert chemicals can be assembled and referenced. Wherever a patient is being delivered a life-saving therapy, sign off on a checklist of steps in preparing the medication can [should] be mandatory. The review of physical status of patients in the emergency room is perhaps the easiest of all to be accommodated, since vital signs and status are readily definable. Note that such an approach should contain a "safe harbor" for the acknowledgment of human and system errors as is routinely performed in the case of failures of airplane safety, including crashes. Otherwise, people will be people are try to hide the problem, making a recurrence inevitable.
The connection with healthcare information technology (HIT) is now at hand. IT professionals have always been friends of check lists. Computer systems are notoriously complex and often are far from intuitive. Hence, the importance of asking the right questions at the right time in the process of trouble shooting the IT system. Healthcare professionals are also longtime friends of checklists for similar reasons, both by training and experience. Sometimes symptoms loudly proclaim what they are; but often they can be misleading or anomalous. The differential diagnosis separates the amateurs from the veterans. Finally, we arrive at a wide area of agreement between these two professions, eager as they are to find some common ground.
Naturally, a three ring binder on a shelf with hard copy is always a handy backup; however, the computer is a ready made medium for delivering advice, including top ten things to watch in the form of a checklist, in real time to a stressed provider. In this case of emergency room and clinics, the hospital information system (HIS) is the choice platform to install, update, and maintain the checklist electronically. However, this means that the performance of the system needs to be consistent with delivery of the information in real time or near real time mode. It also means that the provider should be trained in the expert fast path to the information and need to hunt and peck through too many screens. The latter, of course, would be equivalent to not having a functioning list at all.
And this is where a dose of training in information technology will make a difference. The prognosis is especially favorable if the staff already have a friendly - or at least accepting - relationship with the HIS. It reduces paper work, improves workflow, and allows information sharing to coordinate care of patients.
This is also a rich area for further development and growth as system provide support to the physician in making sure all of the options have been checked. The system does not replace the doctor, but acts like a co-pilot or navigator to perform computationally intense tasks that would otherwise take too much time in situations of high stress and time pressure. Obviously issues of high performance response on the part of the IT system and usability (from the perspective of the professionals staff) loom large here. Look forward to further discussion on these points. Meanwhile, we now add another item to add to the vendor selection checklist in choosing a HIS: must be able to provide templates (and where applicable, content) for clinical checklists by subject matter area.
It should be noted that "the checklist manifesto" is the recommendation in a
book of the same title by the celebrity physician,
 "Potassium may no longer be stocked on patient care units, but serious threats still exist" Oct 4 2007, http://www.ismp.org/newsletters/acutecare/articles/20071004.asp
 "An Injustice has been done," http://www.ismp.org/pressroom/injustice-jailtime-for-pharmacist.asp
Posted August 16, 2010 1:08 PM
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