- Email: [email protected]
Targeting Errors in the ICU: Use of a National Database
Crit Care Nurs Clin N Am 18 (2006) 509–514
Targeting Errors in the ICU: Use of a National Database Ruth Kleinpell, PhD, RN, FAAN, FAANP, FCCMa,b,c,*, David Thompson, DNSc, MS, RNd,e, Lynn Kelso, MSN, RN, FCCMf,g, Peter J. Pronovost, MD, PhDh a
Rush University College of Nursing, Chicago, IL, USA b Rush University Medical Center, Chicago, IL, USA c Our Lady of the Resurrection Medical Center, Chicago, IL, USA d Johns Hopkins University School of Medicine, Baltimore, MD, USA e Johns Hopkins University School of Nursing, Baltimore, MD, USA f University of Kentucky College of Nursing, Lexington, KY, USA g University of Kentucky Chandler Medical Center, Lexington, KY, USA h Departments of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD, USA
Background: focusing on patient safety Patient safety has become a major focus of many health care initiatives, in part because of the Institute of Medicine’s report, ‘‘To Err is Human: Building a Safer Health System,’’ which highlighted the risks of medical care and medical error–related deaths and other serious adverse events [1]. Patient safety initiatives are focused on the prevention of harm to patients [2]. A primary focus for improvement in health care is on promoting patient safety and avoiding injuries to patients from health care that is intended to help them [3]. Research on patient safety has focused on examining adverse outcomes of care, defined as injuries caused by health care rather than by underlying disease [4]. Various medical errors exist (Box 1). Nurses play a significant role in patient safety because they are the health care providers with whom patients are likely to spend the greatest amount of time [5]. In the ICU, the influence of nursing
* Corresponding author. Rush University College of Nursing, 600 South Paulina Street, Suite 1062B, Chicago, IL 60612. E-mail address: [email protected] (R. Kleinpell).
care on patient safety is especially significant; nurses perform most patient assessments and evaluations, and care for patients who are acutely and critically ill and therefore at increased risk for adverse events [6]. Several factors related to nursing care that contribute to patient safety have been explored, including nurse staffing levels, workload, professional qualifications, and work schedules [4,5,7–16]. The focus of patient safety in the ICU has become an established quality indicator. As a result of acuity and complexity of care, the ICU is an environment prone to medical errors [17]. Various factors are associated with adverse events and errors (Box 2). Several evidence-based reviews have focused on opportunities for safety improvement [2,4,5,18,19], highlighting the role of creating and sustaining a culture of safety and establishing comprehensive patient safety systems. Information on patient safety, such as adverse events and near misses, can be used to design even safer health care delivery systems. Although increased attention has been given to factors impacting patient safety, current systems of incident reporting are inadequate in identifying adverse events in hospitals [20].
0899-5885/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2006.08.002
ccnursing.theclinics.com
510
KLEINPELL
Box 1. Types of medical errors
Medication errors Errors in surgery Misdiagnosis Errors in performance of hazardous activities (surgery, anesthesia, radiation therapy, and so forth) Selection of inappropriate treatment Nosocomial infection Data from National Patient Safety Foundation. Agenda for research and development in patient safety. Available at: http://www.npsf. org/download/researchagenda.pdf. Accessed February 15, 2006.
ICU Safety Reporting System A novel incident reporting system was developed recently to report unsafe conditions and events in ICUs that could or did lead to patient harm [21]. The overall goal of the ICU Safety Reporting System (ICUSRS) is to improve patient safety in ICUs through anonymous voluntary reporting. This demonstration project, funded by the US Agency for Health Care Research and Quality, implemented a web-based reporting system in a cohort of ICUs across the United States to 1. Identify and eliminate system failures that lead to errors in health care. 2. Compare near misses to adverse events, with respect to quantity and content of information and opportunity to improve safety.
Box 2. Factors associated with adverse events
Insufficient staffing Inadequate skill mix Failure to follow established protocol Poor communication among teams Incomplete communication during hand-offs Fatigue Inadequate hospital systems Lack of optimal technology Failing to seek or lack of supervision Inadequate training with equipment
et al
3. Examine provider’s perceptions of reporting systems and the effects of participation on safety-related attitudes. 4. Explore the usefulness of the ICU safety reporting system for patient safety initiatives at the institutional and professional society levels [22]. The ICUSRS collects voluntary reports of adverse events and near misses from staff in over 23 ICUs across the United States [23]. The project is conducted in partnership with the Society of Critical Care Medicine (SCCM). Participants include both adult and pediatric ICUs and surgical, medical, trauma, and cardiac services. A study team was assembled at each ICU site, including the ICU director or other ICU attending physician, nurse-manager, nurse-educator, and risk manager. To promote a culture change to a blame-free focus on error reporting, the ICUSRS database was made voluntary, anonymous, and confidential [24]. In contrast to other web-based reporting systems, such as the US Pharmacopeia’s MedMarx System, the Institute for Safe Medication Practices’ Medication Errors Reporting Program, and the Emergency Care Research Institute, which predominantly focus on a specific type of event (eg, medication errors or medical products), the ICUSRS collects information on all types of incidents from multiple ICU settings. The purpose of the ICUSRS is to focus on system failures and their effect on outcomes, not on specific patients or medical providers. Data that are collected include information on the event type (airway, equipment/medical device, information technology, lines, tubes and drains, medication and therapeutics, orders not completed/ delayed, patient assessment and review, patient fall, patient identification, patient restraint, patient testing, skin integrity, other hazardous situation); patient factors (condition, language/ communication, personality, and social factors); provider factors (fatigue, motivation/attitude, physical or mental health); task factors (accuracy of test results, availability of protocols, availability of test results); team factors (team structure and leadership, verbal or written communication during crisis, hand off or routine care); training and education factors (established protocol followed, knowledge, skill and competence, supervision and help sought); information technology factors (computer/software error, computer/software malfunction, user error); ICU environmental factors (administrative and managerial support,
TARGETING ERRORS IN THE ICU: USE OF A NATIONAL DATABASE
availability/maintenance of equipment, physical environment, skill mix, staffing levels, workload); institutional environmental factors (financial resources, laboratory, pharmacy, time); therapies the patient was receiving at the time of the incident; extent of patient harm; patient demographics (gender, age, race); if the event prolonged hospital stay; and other incident descriptor information [23]. Any ICU staff member who sees an incident or a near-miss situation can report to the ICUSRS. The current reporting system consists of nine screens, with two additional screens that appear if the reporter answers ‘‘yes’’ to either the medical device/equipment or medication error questions [24]. The first three screens require a password that is supplied to all ICU staff; the next screen prompts the reporter to identify if the report is a ‘‘new entry’’ or if revisions are being made to a previous submission, and the next allows reporters to identify their ICU [24]. The remaining six screens involve questions about the incident being reported. A final evaluation questionnaire can be accessed at the end of the reporting system by choosing ‘‘continue’’ before confirming submission [24]. The ICUSRS went live on July 1, 2002, and, by the end of the second year of reporting, 2075 adverse events and near misses had been submitted from 23 ICUs. Currently, qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter. A case study is presented to illustrate the use of the ICUSRS and how the reporting data are used to highlight important safety aspects of patient care in the ICU.
Case summary A 65-year-old African-American man was extubated the morning before the event. The patient continued to have a lot of secretions and needed pulmonary toileting, including nasotracheal suctioning (NTS). At 23:50 on the day after extubation, the tube feeding ran dry so it was turned off. At 00:10, the nurse entered the room to check vitals and to start the patient’s bath. The respiratory therapist (RT) was in the room giving a respiratory treatment with NTS. The Head of the Bed (HOB) was elevated less than 20 degrees. The RT was on the left side of bed while the
511
patient was leaning toward the right and facing right. The nurse noted that the tube feed was running out of the patient’s mouth while the RT was giving treatment. Afterward, the HOB was elevated and a bath was given. The patient’s breathing sounded congested. The HOB was then elevated to greater than 45 degrees and the patient received NTS. The patient’s breathing cleared; however, the oxygen (O2) saturation dropped to 73%. A nasal cannula at 2 L was placed on the patient and the O2 saturation improved to 100%. At 01:00, the O2 saturation dropped back down to 78%. Oxygen was increased to 4L from 2L and the patient was stimulated to take deep breaths. The nurse was called out of the room for 45 seconds. The patient’s O2 saturation improved to 83%. When the nurse returned to the room at 01:07, the patient was asystolic. The EKG returned to a rate of 30 without intervention; however, the patient was apneic. A code was called. The patient’s mouth was found to be full of tube feedings. An attempt at resuscitation was made for 20 minutes but was unsuccessful. Aspiration was listed as one of the causes of death. System analysis Several system failures could have contributed to this incident. System failure 1: Policy and procedure Based on the narrative information given, it is difficult to address all the policies and procedures that may have been in place. However: Policy and procedure #1: The house officer or physician should be notified when a physiologic change occurs, such as oxygen desaturation. In this case, if it is suspected that the patient has aspirated, a chest radiograph or other diagnostic test is indicated. There is no indication that a physician was notified of the physiologic change or the possibility of aspiration, especially when tube feeding was noted to be draining from the patient’s mouth. Policy and procedure #2: Many ICUs have a standard policy, unless restricted by orthopedic procedure and so forth, that the HOB is elevated to 30 degrees or higher when a patient is on tube feedings. Also, the patient is usually elevated 45 degrees for NTS. In this case, the patient was not elevated for ease of suctioning or to prevent aspiration, a significant
512
KLEINPELL
risk when the patient’s gag reflex is stimulated. Policy and procedure #3: Some ICUs have adopted a policy to turn tube feedings off before respiratory treatments such as NTS or chest physiotherapy. The RT did not speak with the nurse to know how long the tube feeding had been turned off. System failure 2: Failure of communication/ teamwork Communication between the nurse and the RT was not evident, nor was a plan for the patient’s overall pulmonary toileting. There is little evidence that they worked as a team to plan and provide for the patient’s care. System failure 3: Supervision and seeking help The house officer or physician responsible for the patient’s overall care was not notified, something that is usually done with changes in patient status. There is also no evidence that the RT or the nurse consulted with a senior member of the staff about the possibility of the patient needing assessment and intervention for potential aspiration. Opportunities to improve patient safety Several systems could be changed to reduce the risk of this event happening in the future. The first rule of patient-centered care is to focus on what is best for the patient and not to focus on blaming. Communication/teamwork Patient daily goals 1. As part of the patient’s daily goals, examine if NTS is still indicated, review frequency, and have the physician write parameters for which he/she should be notified. 2. If appropriate, clarify/obtain orders regarding holding tube feedings or how long the patient should be nothing by mouth (NPO) before NTS. Communication and teamwork 1. Keep staff members informed of patients’ needs. 2. Have the RT introduce him/herself to the nursing staff and discuss the pulmonary therapies to be administered during the shift, to optimize patient safety, to keep all team members informed, and to plan around other patient activities such as dressing changes and blood draws.
et al
3. As your patients’ nurse and advocate, identify the physicians covering your patients for the shift. Let the physicians know which patients you are providing care for and if there are any issues you would like addressed at the start of the shift. Inquire about changes in any patient’s treatment, new interventions, or planned tests. Clarify parameters that you notify the physician for if they are unclear. Keep each other informed. 4. Hold periodic multidisciplinary discussions about communication and teamwork in the unit, including discussions of team functioning, and protocol development needs. 5. Reinforce the importance of assertive communications and briefings when a patient needs urgent care. Situation, Background, Assessment, Recommendation. Situation, Background, Assessment, Recommendation (SBAR) is an assertive communication technique, initially used on nuclear naval submarines during emergency situations, that has been adapted to health care. With SBAR, any member of the health care team can implement this structured communication briefing. The Situation is presented, along with the patient’s Background or history, which may include trends in hemodynamic status, neurologic status, and anything that is, or could be, pertinent to providing the best care possible for this patient. The medical team Assesses the situation and makes Recommendations for treatment and testing. This technique not only alerts the medical team to an emergency but obtains the perspectives of all team members (nurses, house staff, other physicians, technicians, RTs, and so forth), decreasing the chance that an important element is missed and allowing the senior member of the group to develop the best plan of care to achieve the optimal patient outcome. Nasotracheal suctioning procedures NTS is a blind, high-risk procedure with many potential complications: Mechanical trauma: irritation, bleeding, perforation of the pharynx, mucosal hemorrhage Nosocomial infection Uncontrolled coughing, gagging, vomiting, and aspiration Bradycardia and other dysrhythmias leading to cardiac arrest Hypoxia, hypoxemia, respiratory arrest
TARGETING ERRORS IN THE ICU: USE OF A NATIONAL DATABASE
Hypertension/hypotension Laryngospasm Nosocomial Pneumonia Increased intracranial pressure (ICP), intraventricular hemorrhage, increased cerebral edema
Procedure for NTS 1. Assess need: Assess breath sounds, effectiveness of the patient’s cough and oxygen saturation, and whether the patient is unable to clear his/her secretions 2. Ready equipment: Oxygen Vacuum source Adjustable regulator Sterile catheter: soft, pliable, and of appropriate caliber Water-based lubricant Resuscitation bag and masked Optional Local anesthetic if indicated/ordered Nasopharyngeal airway 3. Position patient: HOB elevated greater than 30 degrees or per ICU protocol. 4. Lubricate suction catheter and gently introduce into the nares and into the lungs. Suction should be limited to 15 seconds or less. Apply oxygen and repeat as needed. Monitor oxygen saturation, heart rate, rhythm, and blood pressure. Consider certification in respiratory care, NTS, bagging, suctioning a vented patient, and so forth, for new hires and when policy changes have been made. Conduct in-service programs for new policies or when new equipment is being used in the ICU. For more information regarding NTS, see the clinical practice guidelines for NTS at www. rcjournal.com.
513
and near misses. Second, members of the committee developed and presented short case studies of errors or near misses, looking to identify system issues that led to either the error or to preventing the error. Members of the committee could either present a case from their institution or use a case that had been submitted to the ICUSRS. Taxonomy development pilot work was undertaken with the goal of identifying enough categories to be comprehensive but not cumbersome. Medication errors are a good example of the difficulty encountered with this task. Many types of medication errors occur in health care with many different reasons as to why they occur. Developing a taxonomy for each one would be cumbersome. However, enough categories needed to be developed so that participating ICUs could easily categorize the error they were reporting. Failures in the system are what frequently lead to error occurrence and every error can fall easily within a number of categories. Working with the ICUSRS database enabled the committee to strategize for possible taxonomy language. The pilot work provided additional work with the ICUSRS database and served to highlight the complexity involved in formulating taxonomy categories. The second goal of the committee was not only to analyze errors, but also to present them to a broader audience of critical care practitioners. Each case was analyzed for the system failures that allowed for mistakes to happen. Cases were presented on a monthly or bi-monthly basis to members of the SCCM by placing them in the online newsletter and by having links to the cases on the SCCM web page. This strategy proved useful in further disseminating information on the ICUSRS database and also in focusing on error-reduction in the ICU. Additionally, publications on case studies from the ICUSRS have provided individualized case analysis, stressing error prevention [25,26]. Summary
Implications for critical care Using nonjudgmental incident reporting can allow practitioners to evaluate how systems play a role in errors that occur in health care. The SCCM, along with the ICUSRS investigators, formed a committee to review reports that were submitted to the ICUSRS. The purpose of this review was twofold. First, the committee examined cases to determine how taxonomies could be developed from the database to categorize errors
The authors believe that as we move from viewing adverse event reporting systems as punitive, and as the safety culture improves, reporting will likely increase. Voluntary incident reporting systems can be used to improve patient safety in the ICU by identifying broken or inadequate systems that lead to adverse events [26]. Voluntary external reporting systems such as the ICUSRS can be used to target errors and produce evidence-based best practice measures to improve patient safety in the ICU.
514
KLEINPELL
References [1] Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington DC: National Academy Press; 1999. [2] Aspden P, Corrigan JM, Wolcott J, et al. Patient safety: achieving a new standard for care. Washington DC: National Academy of Sciences; 2004. [3] Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001. [4] Hickam DH, Severance S, Feldstein A, et al. The effect of healthcare working conditions on patient safety. Evidence report/technology assessment number 74. AHRQ Publication No. 03-E. Rockville MD: Agency for Healthcare Research and Quality; 2003. [5] Page A, editor. Committee on the work environment for nurses and patient safety. Keeping patients safe: transforming the work environment of nurses. Washington DC: National Academy of Sciences; 2004. [6] Brilli R, Spevetz A, Branson R, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001;29: 2007–19. [7] Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nurs Res 1998;47:42–50. [8] Bond CA, Raehl CL, Pitterle ME, et al. Health care professional staffing, hospital characteristics, and hospital mortality rates. Pharmacotherapy 1999;19: 130–8. [9] Armaravadi RK, Dimick JB, Pronovost PJ, et al. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Med 2000;26:1857–62. [10] Dimick JB, Swoboda SM, Pronovost PJ, et al. Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care 2001;10:376–82. [11] Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract 2001;4:199–206. [12] Lichtig LK, Knauf RA, Milholland DK. Some impacts of nursing on acute care hospital outcomes. J Nurs Adm 1999;29:25–33. [13] Needleman J, Buerhaus P, Mattke S, et al. Nursestaffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715–22.
et al [14] Tarnow-Mordi WO, Hau C, Warden A, et al. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000;356:185–9. [15] Kovner C, Jones C, Zhan C, et al. Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of US hospitals, 1990– 1996. Health Serv Res 2002;37:611–29. [16] Aiken L, Clarke S, Sloane D, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288: 1987–93. [17] Wong N. Medical education in critical care. Journal of Critical Care 2005;20:270–3. [18] Reid PP, Compton WD, Grossman JH, et al, editors. Building a better delivery system: a new engineering/health care partnership. Washington DC: National Academies Press; 2005. [19] Shojania KG, Duncan BW, McDonald KM, et al, editors. Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment No. 43. AHRQ Publication No. 01– E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001. [20] Garland A. Improving the ICU. Chest 2005;127: 2165–79. [21] Pronovost PJ, Nolan T, Zeger S, et al. How can clinicians measure safety and quality in acute care? Lancet 2004;363(9414):1061–7. [22] Needham DM, Sinopoli DJ, Thompson DA, et al. A system factors analysis of ‘‘line, tube, and drain’’ incidents in the intensive care unit. Crit Care Med 2005;33(8):1701–7. [23] Needham DM, Thompson DA, Holzmueller CG, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32(11): 2227–33. [24] Holzmueller CG, Pronovost PJ, Dickman F, et al. Creating the web-based intensive care unit safety reporting system. J Am Med Inform Assoc 2005; 12(2):130–9. [25] Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med 2004;140:1025–33. [26] Thompson DA, Lubomski L, Holzmueller C, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Joint Commission Journal on Quality & Patient Safety 2005;31(10):585–93.
Targeting Errors in the ICU: Use of a National Database Ruth Kleinpell, PhD, RN, FAAN, FAANP, FCCMa,b,c,*, David Thompson, DNSc, MS, RNd,e, Lynn Kelso, MSN, RN, FCCMf,g, Peter J. Pronovost, MD, PhDh a
Rush University College of Nursing, Chicago, IL, USA b Rush University Medical Center, Chicago, IL, USA c Our Lady of the Resurrection Medical Center, Chicago, IL, USA d Johns Hopkins University School of Medicine, Baltimore, MD, USA e Johns Hopkins University School of Nursing, Baltimore, MD, USA f University of Kentucky College of Nursing, Lexington, KY, USA g University of Kentucky Chandler Medical Center, Lexington, KY, USA h Departments of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD, USA
Background: focusing on patient safety Patient safety has become a major focus of many health care initiatives, in part because of the Institute of Medicine’s report, ‘‘To Err is Human: Building a Safer Health System,’’ which highlighted the risks of medical care and medical error–related deaths and other serious adverse events [1]. Patient safety initiatives are focused on the prevention of harm to patients [2]. A primary focus for improvement in health care is on promoting patient safety and avoiding injuries to patients from health care that is intended to help them [3]. Research on patient safety has focused on examining adverse outcomes of care, defined as injuries caused by health care rather than by underlying disease [4]. Various medical errors exist (Box 1). Nurses play a significant role in patient safety because they are the health care providers with whom patients are likely to spend the greatest amount of time [5]. In the ICU, the influence of nursing
* Corresponding author. Rush University College of Nursing, 600 South Paulina Street, Suite 1062B, Chicago, IL 60612. E-mail address: [email protected] (R. Kleinpell).
care on patient safety is especially significant; nurses perform most patient assessments and evaluations, and care for patients who are acutely and critically ill and therefore at increased risk for adverse events [6]. Several factors related to nursing care that contribute to patient safety have been explored, including nurse staffing levels, workload, professional qualifications, and work schedules [4,5,7–16]. The focus of patient safety in the ICU has become an established quality indicator. As a result of acuity and complexity of care, the ICU is an environment prone to medical errors [17]. Various factors are associated with adverse events and errors (Box 2). Several evidence-based reviews have focused on opportunities for safety improvement [2,4,5,18,19], highlighting the role of creating and sustaining a culture of safety and establishing comprehensive patient safety systems. Information on patient safety, such as adverse events and near misses, can be used to design even safer health care delivery systems. Although increased attention has been given to factors impacting patient safety, current systems of incident reporting are inadequate in identifying adverse events in hospitals [20].
0899-5885/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2006.08.002
ccnursing.theclinics.com
510
KLEINPELL
Box 1. Types of medical errors
Medication errors Errors in surgery Misdiagnosis Errors in performance of hazardous activities (surgery, anesthesia, radiation therapy, and so forth) Selection of inappropriate treatment Nosocomial infection Data from National Patient Safety Foundation. Agenda for research and development in patient safety. Available at: http://www.npsf. org/download/researchagenda.pdf. Accessed February 15, 2006.
ICU Safety Reporting System A novel incident reporting system was developed recently to report unsafe conditions and events in ICUs that could or did lead to patient harm [21]. The overall goal of the ICU Safety Reporting System (ICUSRS) is to improve patient safety in ICUs through anonymous voluntary reporting. This demonstration project, funded by the US Agency for Health Care Research and Quality, implemented a web-based reporting system in a cohort of ICUs across the United States to 1. Identify and eliminate system failures that lead to errors in health care. 2. Compare near misses to adverse events, with respect to quantity and content of information and opportunity to improve safety.
Box 2. Factors associated with adverse events
Insufficient staffing Inadequate skill mix Failure to follow established protocol Poor communication among teams Incomplete communication during hand-offs Fatigue Inadequate hospital systems Lack of optimal technology Failing to seek or lack of supervision Inadequate training with equipment
et al
3. Examine provider’s perceptions of reporting systems and the effects of participation on safety-related attitudes. 4. Explore the usefulness of the ICU safety reporting system for patient safety initiatives at the institutional and professional society levels [22]. The ICUSRS collects voluntary reports of adverse events and near misses from staff in over 23 ICUs across the United States [23]. The project is conducted in partnership with the Society of Critical Care Medicine (SCCM). Participants include both adult and pediatric ICUs and surgical, medical, trauma, and cardiac services. A study team was assembled at each ICU site, including the ICU director or other ICU attending physician, nurse-manager, nurse-educator, and risk manager. To promote a culture change to a blame-free focus on error reporting, the ICUSRS database was made voluntary, anonymous, and confidential [24]. In contrast to other web-based reporting systems, such as the US Pharmacopeia’s MedMarx System, the Institute for Safe Medication Practices’ Medication Errors Reporting Program, and the Emergency Care Research Institute, which predominantly focus on a specific type of event (eg, medication errors or medical products), the ICUSRS collects information on all types of incidents from multiple ICU settings. The purpose of the ICUSRS is to focus on system failures and their effect on outcomes, not on specific patients or medical providers. Data that are collected include information on the event type (airway, equipment/medical device, information technology, lines, tubes and drains, medication and therapeutics, orders not completed/ delayed, patient assessment and review, patient fall, patient identification, patient restraint, patient testing, skin integrity, other hazardous situation); patient factors (condition, language/ communication, personality, and social factors); provider factors (fatigue, motivation/attitude, physical or mental health); task factors (accuracy of test results, availability of protocols, availability of test results); team factors (team structure and leadership, verbal or written communication during crisis, hand off or routine care); training and education factors (established protocol followed, knowledge, skill and competence, supervision and help sought); information technology factors (computer/software error, computer/software malfunction, user error); ICU environmental factors (administrative and managerial support,
TARGETING ERRORS IN THE ICU: USE OF A NATIONAL DATABASE
availability/maintenance of equipment, physical environment, skill mix, staffing levels, workload); institutional environmental factors (financial resources, laboratory, pharmacy, time); therapies the patient was receiving at the time of the incident; extent of patient harm; patient demographics (gender, age, race); if the event prolonged hospital stay; and other incident descriptor information [23]. Any ICU staff member who sees an incident or a near-miss situation can report to the ICUSRS. The current reporting system consists of nine screens, with two additional screens that appear if the reporter answers ‘‘yes’’ to either the medical device/equipment or medication error questions [24]. The first three screens require a password that is supplied to all ICU staff; the next screen prompts the reporter to identify if the report is a ‘‘new entry’’ or if revisions are being made to a previous submission, and the next allows reporters to identify their ICU [24]. The remaining six screens involve questions about the incident being reported. A final evaluation questionnaire can be accessed at the end of the reporting system by choosing ‘‘continue’’ before confirming submission [24]. The ICUSRS went live on July 1, 2002, and, by the end of the second year of reporting, 2075 adverse events and near misses had been submitted from 23 ICUs. Currently, qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter. A case study is presented to illustrate the use of the ICUSRS and how the reporting data are used to highlight important safety aspects of patient care in the ICU.
Case summary A 65-year-old African-American man was extubated the morning before the event. The patient continued to have a lot of secretions and needed pulmonary toileting, including nasotracheal suctioning (NTS). At 23:50 on the day after extubation, the tube feeding ran dry so it was turned off. At 00:10, the nurse entered the room to check vitals and to start the patient’s bath. The respiratory therapist (RT) was in the room giving a respiratory treatment with NTS. The Head of the Bed (HOB) was elevated less than 20 degrees. The RT was on the left side of bed while the
511
patient was leaning toward the right and facing right. The nurse noted that the tube feed was running out of the patient’s mouth while the RT was giving treatment. Afterward, the HOB was elevated and a bath was given. The patient’s breathing sounded congested. The HOB was then elevated to greater than 45 degrees and the patient received NTS. The patient’s breathing cleared; however, the oxygen (O2) saturation dropped to 73%. A nasal cannula at 2 L was placed on the patient and the O2 saturation improved to 100%. At 01:00, the O2 saturation dropped back down to 78%. Oxygen was increased to 4L from 2L and the patient was stimulated to take deep breaths. The nurse was called out of the room for 45 seconds. The patient’s O2 saturation improved to 83%. When the nurse returned to the room at 01:07, the patient was asystolic. The EKG returned to a rate of 30 without intervention; however, the patient was apneic. A code was called. The patient’s mouth was found to be full of tube feedings. An attempt at resuscitation was made for 20 minutes but was unsuccessful. Aspiration was listed as one of the causes of death. System analysis Several system failures could have contributed to this incident. System failure 1: Policy and procedure Based on the narrative information given, it is difficult to address all the policies and procedures that may have been in place. However: Policy and procedure #1: The house officer or physician should be notified when a physiologic change occurs, such as oxygen desaturation. In this case, if it is suspected that the patient has aspirated, a chest radiograph or other diagnostic test is indicated. There is no indication that a physician was notified of the physiologic change or the possibility of aspiration, especially when tube feeding was noted to be draining from the patient’s mouth. Policy and procedure #2: Many ICUs have a standard policy, unless restricted by orthopedic procedure and so forth, that the HOB is elevated to 30 degrees or higher when a patient is on tube feedings. Also, the patient is usually elevated 45 degrees for NTS. In this case, the patient was not elevated for ease of suctioning or to prevent aspiration, a significant
512
KLEINPELL
risk when the patient’s gag reflex is stimulated. Policy and procedure #3: Some ICUs have adopted a policy to turn tube feedings off before respiratory treatments such as NTS or chest physiotherapy. The RT did not speak with the nurse to know how long the tube feeding had been turned off. System failure 2: Failure of communication/ teamwork Communication between the nurse and the RT was not evident, nor was a plan for the patient’s overall pulmonary toileting. There is little evidence that they worked as a team to plan and provide for the patient’s care. System failure 3: Supervision and seeking help The house officer or physician responsible for the patient’s overall care was not notified, something that is usually done with changes in patient status. There is also no evidence that the RT or the nurse consulted with a senior member of the staff about the possibility of the patient needing assessment and intervention for potential aspiration. Opportunities to improve patient safety Several systems could be changed to reduce the risk of this event happening in the future. The first rule of patient-centered care is to focus on what is best for the patient and not to focus on blaming. Communication/teamwork Patient daily goals 1. As part of the patient’s daily goals, examine if NTS is still indicated, review frequency, and have the physician write parameters for which he/she should be notified. 2. If appropriate, clarify/obtain orders regarding holding tube feedings or how long the patient should be nothing by mouth (NPO) before NTS. Communication and teamwork 1. Keep staff members informed of patients’ needs. 2. Have the RT introduce him/herself to the nursing staff and discuss the pulmonary therapies to be administered during the shift, to optimize patient safety, to keep all team members informed, and to plan around other patient activities such as dressing changes and blood draws.
et al
3. As your patients’ nurse and advocate, identify the physicians covering your patients for the shift. Let the physicians know which patients you are providing care for and if there are any issues you would like addressed at the start of the shift. Inquire about changes in any patient’s treatment, new interventions, or planned tests. Clarify parameters that you notify the physician for if they are unclear. Keep each other informed. 4. Hold periodic multidisciplinary discussions about communication and teamwork in the unit, including discussions of team functioning, and protocol development needs. 5. Reinforce the importance of assertive communications and briefings when a patient needs urgent care. Situation, Background, Assessment, Recommendation. Situation, Background, Assessment, Recommendation (SBAR) is an assertive communication technique, initially used on nuclear naval submarines during emergency situations, that has been adapted to health care. With SBAR, any member of the health care team can implement this structured communication briefing. The Situation is presented, along with the patient’s Background or history, which may include trends in hemodynamic status, neurologic status, and anything that is, or could be, pertinent to providing the best care possible for this patient. The medical team Assesses the situation and makes Recommendations for treatment and testing. This technique not only alerts the medical team to an emergency but obtains the perspectives of all team members (nurses, house staff, other physicians, technicians, RTs, and so forth), decreasing the chance that an important element is missed and allowing the senior member of the group to develop the best plan of care to achieve the optimal patient outcome. Nasotracheal suctioning procedures NTS is a blind, high-risk procedure with many potential complications: Mechanical trauma: irritation, bleeding, perforation of the pharynx, mucosal hemorrhage Nosocomial infection Uncontrolled coughing, gagging, vomiting, and aspiration Bradycardia and other dysrhythmias leading to cardiac arrest Hypoxia, hypoxemia, respiratory arrest
TARGETING ERRORS IN THE ICU: USE OF A NATIONAL DATABASE
Hypertension/hypotension Laryngospasm Nosocomial Pneumonia Increased intracranial pressure (ICP), intraventricular hemorrhage, increased cerebral edema
Procedure for NTS 1. Assess need: Assess breath sounds, effectiveness of the patient’s cough and oxygen saturation, and whether the patient is unable to clear his/her secretions 2. Ready equipment: Oxygen Vacuum source Adjustable regulator Sterile catheter: soft, pliable, and of appropriate caliber Water-based lubricant Resuscitation bag and masked Optional Local anesthetic if indicated/ordered Nasopharyngeal airway 3. Position patient: HOB elevated greater than 30 degrees or per ICU protocol. 4. Lubricate suction catheter and gently introduce into the nares and into the lungs. Suction should be limited to 15 seconds or less. Apply oxygen and repeat as needed. Monitor oxygen saturation, heart rate, rhythm, and blood pressure. Consider certification in respiratory care, NTS, bagging, suctioning a vented patient, and so forth, for new hires and when policy changes have been made. Conduct in-service programs for new policies or when new equipment is being used in the ICU. For more information regarding NTS, see the clinical practice guidelines for NTS at www. rcjournal.com.
513
and near misses. Second, members of the committee developed and presented short case studies of errors or near misses, looking to identify system issues that led to either the error or to preventing the error. Members of the committee could either present a case from their institution or use a case that had been submitted to the ICUSRS. Taxonomy development pilot work was undertaken with the goal of identifying enough categories to be comprehensive but not cumbersome. Medication errors are a good example of the difficulty encountered with this task. Many types of medication errors occur in health care with many different reasons as to why they occur. Developing a taxonomy for each one would be cumbersome. However, enough categories needed to be developed so that participating ICUs could easily categorize the error they were reporting. Failures in the system are what frequently lead to error occurrence and every error can fall easily within a number of categories. Working with the ICUSRS database enabled the committee to strategize for possible taxonomy language. The pilot work provided additional work with the ICUSRS database and served to highlight the complexity involved in formulating taxonomy categories. The second goal of the committee was not only to analyze errors, but also to present them to a broader audience of critical care practitioners. Each case was analyzed for the system failures that allowed for mistakes to happen. Cases were presented on a monthly or bi-monthly basis to members of the SCCM by placing them in the online newsletter and by having links to the cases on the SCCM web page. This strategy proved useful in further disseminating information on the ICUSRS database and also in focusing on error-reduction in the ICU. Additionally, publications on case studies from the ICUSRS have provided individualized case analysis, stressing error prevention [25,26]. Summary
Implications for critical care Using nonjudgmental incident reporting can allow practitioners to evaluate how systems play a role in errors that occur in health care. The SCCM, along with the ICUSRS investigators, formed a committee to review reports that were submitted to the ICUSRS. The purpose of this review was twofold. First, the committee examined cases to determine how taxonomies could be developed from the database to categorize errors
The authors believe that as we move from viewing adverse event reporting systems as punitive, and as the safety culture improves, reporting will likely increase. Voluntary incident reporting systems can be used to improve patient safety in the ICU by identifying broken or inadequate systems that lead to adverse events [26]. Voluntary external reporting systems such as the ICUSRS can be used to target errors and produce evidence-based best practice measures to improve patient safety in the ICU.
514
KLEINPELL
References [1] Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington DC: National Academy Press; 1999. [2] Aspden P, Corrigan JM, Wolcott J, et al. Patient safety: achieving a new standard for care. Washington DC: National Academy of Sciences; 2004. [3] Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001. [4] Hickam DH, Severance S, Feldstein A, et al. The effect of healthcare working conditions on patient safety. Evidence report/technology assessment number 74. AHRQ Publication No. 03-E. Rockville MD: Agency for Healthcare Research and Quality; 2003. [5] Page A, editor. Committee on the work environment for nurses and patient safety. Keeping patients safe: transforming the work environment of nurses. Washington DC: National Academy of Sciences; 2004. [6] Brilli R, Spevetz A, Branson R, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001;29: 2007–19. [7] Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nurs Res 1998;47:42–50. [8] Bond CA, Raehl CL, Pitterle ME, et al. Health care professional staffing, hospital characteristics, and hospital mortality rates. Pharmacotherapy 1999;19: 130–8. [9] Armaravadi RK, Dimick JB, Pronovost PJ, et al. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Med 2000;26:1857–62. [10] Dimick JB, Swoboda SM, Pronovost PJ, et al. Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care 2001;10:376–82. [11] Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract 2001;4:199–206. [12] Lichtig LK, Knauf RA, Milholland DK. Some impacts of nursing on acute care hospital outcomes. J Nurs Adm 1999;29:25–33. [13] Needleman J, Buerhaus P, Mattke S, et al. Nursestaffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715–22.
et al [14] Tarnow-Mordi WO, Hau C, Warden A, et al. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000;356:185–9. [15] Kovner C, Jones C, Zhan C, et al. Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of US hospitals, 1990– 1996. Health Serv Res 2002;37:611–29. [16] Aiken L, Clarke S, Sloane D, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288: 1987–93. [17] Wong N. Medical education in critical care. Journal of Critical Care 2005;20:270–3. [18] Reid PP, Compton WD, Grossman JH, et al, editors. Building a better delivery system: a new engineering/health care partnership. Washington DC: National Academies Press; 2005. [19] Shojania KG, Duncan BW, McDonald KM, et al, editors. Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment No. 43. AHRQ Publication No. 01– E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001. [20] Garland A. Improving the ICU. Chest 2005;127: 2165–79. [21] Pronovost PJ, Nolan T, Zeger S, et al. How can clinicians measure safety and quality in acute care? Lancet 2004;363(9414):1061–7. [22] Needham DM, Sinopoli DJ, Thompson DA, et al. A system factors analysis of ‘‘line, tube, and drain’’ incidents in the intensive care unit. Crit Care Med 2005;33(8):1701–7. [23] Needham DM, Thompson DA, Holzmueller CG, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32(11): 2227–33. [24] Holzmueller CG, Pronovost PJ, Dickman F, et al. Creating the web-based intensive care unit safety reporting system. J Am Med Inform Assoc 2005; 12(2):130–9. [25] Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med 2004;140:1025–33. [26] Thompson DA, Lubomski L, Holzmueller C, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Joint Commission Journal on Quality & Patient Safety 2005;31(10):585–93.