Published in the January 2005 issue of Today’s Hospitalist
When Clarian Health Partners decided to introduce a new type of insulin syringe to protect nurses from needlesticks, no one argued with the idea. The syringe featured a needle guard that moves up and down before and after an injection, giving nurses a little extra protection.
When nurses started to use the syringes, however, they quickly discovered some problems. For one, nurses had to read some of the hash marks on the syringes by peering through the opaque plastic of the needle guard. It was difficult to see the numbers through the thick shield “and to make sure that patients were receiving the right dose of insulin.
Making matters worse, all of the hash marks didn’t appear on the same side of the needle. While one side of the barrel displayed the numbers one through 50, nurses had to turn to the other side to see the numbers 50 through 100.
While the needles were supposed to prevent needlesticks, nurses worried the new syringes were going to lead to dosing mistakes. “The syringes created a lot of confusion and near misses, where nurses almost gave the wrong dose of insulin,” explains Kathy McEwen, RN, MBA, patient safety coordinator at Clarian, a health system in Indianapolis with three hospitals and several outpatient facilities in the surrounding area.
But because of a program known as Safe Passage, Clarian was able to quickly head off any serious problems. Nurses began alerting officials at the health system about the potential for trouble, and the new syringes were quickly pulled.
In most hospitals, similar concerns could take months or even years to reach top decision-makers. Clarian, however, has used the Safe Passage program to streamline how nurses and other clinicians identify patient safety concerns ” and how leadership at the health system acts on those concerns.
The Safe Passage program was the brainchild of Clarian’s chief nurse executive, Karlene Kerfoot, RN. About three years ago, the health system’s patient safety experts began training a group of 25 nurses to think about patient safety issues. The goal was to make sure there was a local patient safety expert on each unit.
Ms. McEwen says that the program has focused on “work complexity.” The concept emphasizes that most errors lie not with individuals, but system-wide problems that allow errors to slip through the cracks.
While many health care organizations pay lip service to the notion that systems, not individuals, are to blame for most errors, Clarian has put the idea into practice with the Safe Passage program.
The program starts with an initial training session that lasts between two and four hours. These sessions are supplemented by monthly meetings and educational sessions throughout the year.
Ms. McEwen explains that the training sessions teach staff to think about systems issues so they can identify gaps before patients are hurt. And while Safe Passage representatives are charged with identifying problems in their environment, they are also encouraged to pass that way of thinking onto other staff in their unit.
While the representatives have a physical presence in their units, Ms. McEwen says that the goal is to help improve quality even when the program’s representatives are not on duty.
“It’s not looked at as a staffing issue,” Ms. McEwen says. “We look at it more as a process issue. It doesn’t matter that the Safe Passage nurse isn’t working today, because that person has already educated her department about what she has learned.”
The Safe Passage program caught on so quickly that Clarian has now trained more than 200 staff members. The health system expanded the program beyond nurses, and representatives now include clinical pharmacists, respiratory therapists, radiologic technologists and lab personnel.
The program has recruited staff members from so many different areas, Ms. McEwen says, because it aims to defer to staff with the appropriate expertise.
“That’s not necessarily deferring to the CEO or president of a particular division,” she explains. “It means deferring to the person who does the job in a particular situation. It could be the unit secretary who does a chart check to ensure that an order is adequately written and clear before it is entered into the computer. In that case, the unit secretary is the expert.”
That emphasis on rank-and-file participation has directly influenced the individuals chosen to serve on the Safe Passage team. “Our safety representatives are front-line people,” she explains. “We don’t believe in loading it with people who are not directly involved in doing the work at hand. We need people who appreciate the work complexity.”
To illustrate, Ms. McEwen recalls how the health system handled problems that nurses were having administering the correct IV fluids. Instead of creating a complex process to help nurses make sure they were giving patients the correct IV fluid, Safe Passage representatives conducted focus groups with nurses to get to the bottom of the problem.
Officials quickly found problems in the storage areas where IV fluids were kept. Because the shelves holding IV bags were disorganized, nurses would sometimes take it upon themselves to organize the bags. They would make up their own labels using silk tape and markers to help identify what was in each bag.
That’s where the trouble began, Ms. McEwen explains. The handwriting on these handmade labels was often hard to read, which led to mistakes. Nurses would sometimes simply misunderstand what was written on the labels because it was too small or illegible.
When clerks in charge of stocking these rooms encountered this chaotic system, they would often make matters worse by making their own labels in an effort to impose some order. In some instances, a handwritten label was placed over the stock label, confusing whoever was pulling medications from the IV bin.
Ms. McEwen says that on more than one occasion, the wrong IV fluids were given to patients. “Labels were being juxtaposed on each other,” she says. “Nurses were thinking that they were hanging one IV solution, D5.45 without potassium, but they were actually hanging D5.45 with potassium.”
Today, IV bags are stocked on shelves with computer generated, not handwritten, labels. Clarian also uses a color coded system that calls for clinical labels to be printed on bright yellow paper and stock number labels to be printed on a bright neon green paper.
The health system discourages employees from putting handwritten labels on IV storage devices. Employees are also reminded to read the manufacturer’s label on the bag.
While Ms. McEwen acknowledges that there are still occasional problems with IV bags, she notes that Clarian immediately reduced problems after implementing the program.
While the Safe Passage program has helped address individual issues, it has made even bigger gains in changing the patient safety culture at Clarian. As an example, Ms. McEwen notes that after the health system introduced the new insulin syringe, nurses were not shy about pointing out problems.
“I was being contacted by dozens of nurses,” she recalls. “They were so concerned about this new device that had been introduced on the unit. They were taught that they were supposed to speak up when they saw something that would harm their patients.”
While Clarian is still tracking and analyzing the program’s effect on patient safety, Ms. McEwen says she has seen plenty of anecdotal evidence of progress. “It’s possible that we’re going to know about a safety hazard before there is ever an occurrence report,” she says, “or before anything ever happens to a patient. We’re seeing many more near misses, and our incident reporting has increased 100 fold.”
And while some may consider changing attitudes a soft measure of success, it is a critical step in improving patient safety.
“If you measure your number of falls and they go down, that’s great,” says Paul Calkins, MD, an anesthesiologist who recently became involved with the project. “But if that number goes up, that could be a positive outcome, because it may mean that you’re catching people who wouldn’t have normally been reported. It’s a cultural issue that you’re getting people to report safety issues.”
Edward Doyle is Editor of Today’s Hospitalist.