Patient Safety: Lessons We Continue to Learn
Standard Work Improves Patient Safety
Steve Chinn, DPM, Director, Accreditation, Quality & Patient Safety
Over the past year, we have had an opportunity to share some adverse patient events with the medical staff. One of the common factors that contribute to patient harm and near misses is the deviation from Stanford Hospital & Clinics' policies and procedures. In the "lean" world, this could be interpreted as deviation from or lack of standard work.
Recently, we wrote about a near miss where the wrong blood product was almost transfused into a patient. The standard work as outlined in our Patient Care policies specifically states that the transfusionist (the physician in this case) must check the blood product at the patient’s bedside with a second licensed person to verify that the blood product to be transfused is the correct unit for that patient. In this case, neither physician caring for the patient checked, each assuming that the other or the nurse involved had already performed these checks.
Standard work is a powerful lean tool. Standard work and policies/procedures can be considered synonymous. The current hospital policy for blood transfusion was developed with input from transfusion services, and guidance from physicians and nurses involved with the transfusion process. It uses the Joint Commission's National Patient Safety Goal as a reference. This standard work forms the baseline for a cycle of continuous improvement. As the standard is enhanced based on evidence-based information or practice, the new standard becomes the baseline upon which further improvements can be made.
However, in this case, when individuals did not follow the standard process as outlined in policy, process variations occurred. The near miss was avoided when the nurse recognized that the paperwork did not correspond to the patient's name and medical record number. The process was immediately stopped, avoiding a potential disaster.
The following is a short list of standard work adopted by SHC to prevent patient harm and improve clinical outcomes:
|
1
Standard Work |
1
Designed to Prevent |
|
1
Hand hygiene |
1
Spreading infections |
|
1
Medication reconciliation: Review of patient's current medication prior to ordering new medications or adjusting medication regiment |
1
Therapeutic duplication or adverse drug event |
|
1
Labeling of syringes after drawing up medications |
1
Wrong medication administration |
|
1
Marking of procedure site when location or laterality may be confused. |
1
Performing procedure on the wrong location |
|
1
The procedure team stops all activity, when performing the "time out." |
1
Performing a procedure on the wrong patient or location, or performing the wrong procedure. |
|
1
Core Measure compliance |
1
Long lengths of stay and readmissions |
Patient harm contributes to a considerable amount of waste, which in the current era of health care reform is unacceptable. As we move into 2014, our goal is to continue sharing events, both actual and near misses, so that we can all learn from each other’s experience and ultimately provide excellent care to all of our patients.
If you have ideas for improving patient care or just want to talk about your experiences with patient safety, contact Steve Chinn, DPM at sdchinn@stanfordmed.org or (650) 723-6395. Happy Holidays!
By Steve Chinn, DPM, director, Accreditation, Quality & Patient Safety