SAFETY TIP

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.
Reference: Sexton, J.B. (2004). Golden Rules of Group Interaction in High Risk
Environments: Evidence based suggestions for improving performance. Book.
“Leaders Toward Safety ”
Summarized & compiled by : Satrio Pratomo
Gottlieb Daimler and Karl Benz Foundation and Swiss Re Centre for Global
Dialogue. Ladenburg & Rueschlikon. National Transportation Safety Board
(1994), Safety Study: A Review of Flight crew-involved, Major Accidents of U.S.
Air Carriers, 1978 through 1990, PB94-917001, NTSB/SS-94/01, Author,
Washington, DC.


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.


SAFETY TIP # 3 - LEAD IN A PINCH, CEDE IN A CINCH
(ENCOURAGE LEADERSHIP BEHAVIOR IN UNSTRUCTURED
SITUATIONS BUT NOT IN ROUTINE SITUATIONS)
Why? Leadership behaviors are most important in situations that are complex,
unusual, or high workload. In fact, research has shown that the presence of
leadership behaviors during routine or standardized situations is associated with
poor outcomes. During routine situations, a leader who is present but does not
have to actively engage a technical task should take the opportunity to observe
“Leaders Toward Safety ”
Summarized & compiled by : Satrio Pratomo
the strengths and weaknesses of the team as this knowledge is critical during
less routine situations, when the ability to predict and understand the behaviors
of others is essential.
An example: A patient with a very unstable airway and a recent tracheotomy
(surgical incision into the trachea through the neck) suddenly suffered an
obstructed airway and within a few seconds was experiencing life threatening
hypoxia (low blood oxygen levels) and hypotension. The resident and fellow were
not sure how to manage the patient, and had been unsuccessfully paging the
ICU attending for the past several minutes. A surgical attending unfamiliar with
the patient happened upon the scene in the ICU and immediately assumed
charge of the patients care. She attempted dilation of the airway unsuccessfully.
She requested a scalpel and a replacement trachea, replaced the artificial airway
and stabilized the patient while the resident and fellow stepped aside to assist
her. Within a few minutes, the patient stabilized and the attending left the care of
the patient in the hands of the fellow.
Reference: Kerr, S. and Jermier, J. M. (1978). "Substitutes for leadership: Their
Meaning and Measurement." Organizational Behavior and Human performance
22: 375-403 Zaccaro, S., J., A. Rittman, L., et al. (2001). "Team leadership." The
Leadership Quarterly 12: 451-483. 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.


SAFETY TIP # 4 - INCREASE TRANSPARENCY AND REDUCE
AMBIGUITY IN MULTIDISCIPLINARY ENVIRONMENTS USING
DAILY GOALS.
Why? We often lose time and information in multidisciplinary settings because
transparency of actions between and within disciplines requires discussions with
colleagues from other disciplines in various physical locations with differing
degrees of accessibility. Setting public daily goals (click here for an example) for
a given patient using a goals sheet attached to a clipboard at each bedside
enhances the transparency of actions and intentions between and within
disciplines for "this patient, in this bed, today." Daily goals are associated with a
50% decrease in length of stay, by providing a public record of thought
processes and decision making by the multidisciplinary team.
An example: During rounds the attending physician and fellow agreed that it was
best to gently diurese the patient in order to move toward extubation. The patient
“Leaders Toward Safety ”
Summarized & compiled by : Satrio Pratomo
had a history of coronary artery disease patient was the one that he part and
chronic renal insufficiency (the patient was greater than 10 kg above preoperative
weight). By the end of the day, the patient was stable and progressing
according to plan. After evening rounds the attending went home and the senior
resident wrote to increase the lasix gtt to 3 mg an hour. This deviation in the plan
of care resulted in the patient becoming hypotensive requiring fluid boluses and
and a neosynepherine gtt to stabilize the patient's blood pressure. Extubation
was delayed and length of stay was increased by 2 days.
Reference: Pronovost, P.J., Berenholtz, S., Dorman, T., Lipsett, P.A.,
Simmonds, T., and Haraden, C. (2003). Improving communication in the ICU
using daily goals. Journal of Critical Care. June; 18(2): 171-5.