Tuesday, July 21, 2009

SAFETY TIP # 2 - ASK EARLY IF YOU HAVE A QUESTION

SAFETY TIP # 2 - ASK EARLY IF YOU HAVE A QUESTION
ABOUT A TASK TO BE DONE LATER.
Why? Mistakes often occur because care team members lack clarity about
exactly what they are to do, or when they are to do it. Research has shown that
asking a question early (rather than asking the same question later) not only
reduces the risk of failure or injury, but also saves time and reduces the stress
that comes with ambiguity and uncertainty.
An example: An intern joined rounds late. At the end of rounds, the senior house
officer noted that it was time to remove the first of the two chest tubes in an
elderly patient. While everyone present nodded in agreement, the task was given
to the late intern, who did not know which tube was placed first and did not feel
comfortable asking after having nodded knowingly moments before. He
incorrectly assumed the patient was the one that he participated in rounds on.
Later, the intern went to carry out the task, and incorrectly removed what looked
like the older tube. Had he asked questions when first assigned the task, he
would not have removed the wrong chest tube from the wrong patient. This
caused the patient respiratory distress requiring placement of another chest tube.
Reference: Sexton, J.B. (2004). Golden Rules of Group Interaction in High Risk
Environments: Evidence based suggestions for improving performance. Book.
Gottlieb Daimler and Karl Benz Foundation and Swiss Re Centre for Global
Dialogue. Ladenburg & Rueschlikon.

“Leaders Toward Safety ”

SAFETY TIP # 1 - EFFECTIVE LEADERS DELEGATE SO THAT
THEY CAN REGULATE. DURING TIMES OF HEAVY WORKLOAD,
LEADERS SHOULD MANAGE THE SITUATION WHILE OTHERS
MANAGE THE ACTUAL TASKS.
Why? Research has shown that such a strategy reduces multitasking and
improves decision-making and vigilance. Leaders who fail to delegate during high
workload risk increased errors and accidents due to the burden of trying to
simultaneously managing the tasks, the team, and the environment. Evidence of
this phenomenon comes from a handy statistic in commercial aviation. The
National Transportation Safety Board found a disproportionately high percentage
of aviation accidents (over 80%) occur when the captain is the pilot doing the
actual flying and the first officer is the pilot "not flying." These captains are
overloaded as they try to accomplish flight tasks and command duties at the
same time.
An example: in our own industry involved a charge nurse failing to delegate. A
patient with a history of an elevated heart rate spontaneously went into a fast
irregular rhythm. The bedside nurse called out for help when the rhythm caused
a significant drop in blood pressure. The charge nurse, three additional bedside
nurses, and the medical resident arrived at the bedside. The resident ordered an
intravenous medication, which the charge nurse went to obtain and then
administered. Rather than delegate the task to the other staff members, which
would allow her to better supervise and document the efforts of the staff, the
charge nurse sent the other three nurses away stating she could handle the
situation. The patient did not respond to the medication and the physician
ordered that the patient be cardioverted (an electrical shock to trigger a normal
rhythm) and that a continuous medication be given intravenously. The charge
nurse left to mix the medication and get the defibrillator machine. The charge
nurse returned to administer the electric shock with the physician present. The
patient continued to deteriorate and needed additional treatment that was
delayed because the charge nurse did not delegate tasks to the other team
members. The patient suffered mild heart ischemia, and a low oxygen level that
required mechanical ventilation to assist breathing, and resulted in a prolonged
ICU stay.