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November 20, 2018
Checklist Implementation
A recent survey of pediatric surgeons regarding surgical safety checklists (SSCs) revealed some disturbing, but not really surprising, results (Roybal 2018). While 93.6% of respondents use SSCs and 62.6% would want one used in their own child’s operation, only 54.7% felt that checklists improve patient safety.
Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation.
Checklists are incredibly valuable safety tools in healthcare and many other industries. But their implementation encounters all the barriers that implementation of any change project encounters. Like almost any change project, things that are imposed from the outside are doomed to failure. And, when you don’t encounter some “noise” early during implementation, you are also likely doomed.
Some of the comments in the Roybal pediatric study are particularly insightful.
“Checklists only work if they are short.” That is a point we’ve made several times. In our recent October 30, 2018 Patient Safety Tip of the Week “Interhospital Transfers”, we broke down a long checklist into several shorter checklists to facilitate use.
“There are generic elements to all surgical procedures that have some applications in the generic checklists currently available. What would be far more effective would be computer generated checklists SPECIFIC for the procedure scheduled.” A good point. You wouldn’t want a checklist designed for a 747 if you were flying an airbus. So why would you want to use a checklist designed for a cholecystectomy when you are doing a total hip replacement? But some checklists may apply to all types of surgery. For example, malignant hyperthermia might occur in almost any surgical procedure, so a checklist specific for malignant hyperthermia could be used during any surgical procedure if malignant hyperthermia were suspected.
“All this devotion to checklists and process has become a form of fetishism, and often is a distraction from the task at hand.” In our May 2015 What's New in the Patient Safety World column “The Great Checklist Debate” we discussed “checklist fatigue”.
“There may be one case in 10,000 in which it makes a difference. I personally haven’t seen it.” Failure to make a compelling case as to why a particular checklist is needed is one of the biggest barriers to checklist adoption.
“The surgical checklist is highly ineffective in modern Western hospitals. This was shown, but ignored, in the original paper. It is a meme, a trend, and a fad. It does not actually improve real mindfulness, and often distracts from it.” Perhaps a little bit of truth and a lot of chutzpah in that statement! See our What's New in the Patient Safety World columns for April 2014 “Checklists Don’t Always Lead to Improvement” and May 2015 “The Great Checklist Debate”.
Fortunately, there is now a terrific resource available to help with meaningful implementation of checklists. The OR Emergency Checklist Implementation Toolkit, from Ariadne Labs, Emergency Manuals Implementation Collaborative (EMIC), and Stanford University School of Medicine, takes you through all the steps necessary in successful checklist implementation.
Researchers involved in development of that toolkit used data gathered through a Web-based survey to examine factors that might be related to success in implementing OR cognitive aids (Alidina 2018).
Completing more implementation steps was significantly associated with more successful implementation. In fact, each implementation step completed was associated with just over 50% higher odds of more successful implementation. Leadership support and dedicated time to train staff were other factors associated with successful implementation. Small facility size was also associated with a fourfold increase in the odds of a facility reporting more successful implementation. Previous quality improvement experience was associated with success in OR cognitive aid implementation: the greater its number of quality improvement initiatives, the more likely a facility was to successfully implement OR cognitive aids. More successful implementation was associated with the use of the tool in emergency drills, in preparation for complex cases, and in debriefing after a critical event.
Factors associated with less successful implementation were resistance among clinical providers to using cognitive aids, absence of an implementation champion, and unsatisfactory content or design of the cognitive aid,
The following were associated with more successful implementations:
So the OR Emergency Checklist Implementation Toolkit, recommends the following strategies:
The toolkit tells you to expect to spend 6-12 months or more for implementation and training.
The need for a clinical champion speaks for itself. In getting buy-in, it’s important to get support of clinical and administrative leadership. Early communication and outreach to staff is essential. Key hospital leaders need to be engaged in a multidisciplinary implementation team. Get the word out about the project at department meetings and joint conferences.
A key feature of any successful change project is also to identify key people who are likely to resist the change and meet with them 1-on-1 and invest time in educating them about project. In-house marketing (videos, other promotional materials, periodic announcements and updates, etc.) can be helpful.
Since this toolkit is specifically about OR checklists, you need to establish a multidisciplinary team that is representative of all perioperative personnel. Best team members are thoughtful, respected, reliable, collaborative, able to participate, and experienced in quality improvement. They don’t have to be titled leaders.
After you’ve selected checklist(s), customize them to fit your clinical setting. The toolkit provides good recommendations about the pros and cons of printed vs. electronic checklists and provides practical recommendations about best format, visual design, writing style, etc. Test your checklists in team simulations and revise them as necessary. Train your staff on use of the checklists and utilize any of several simulation techniques described in the toolkit. One key success factor is ensuring that time is provided for training of staff.
Phase in your checklists. Don’t roll them out to all areas at once. Get them up and running in a few key areas, learn from them, tweak them, and test them again.
Monitor the use of the checklists. Which ones are being used? Encourage their use and provide feedback on both their use and usefulness.
Share your successes with other areas of the organization (emergency department, ICU’s, labor & delivery, etc.) so they can model similar checklist implementations.
You’ve heard us over and over use the phrase “stories, not statistics”. At each stage where you are training or promoting a checklist, try to give a personal story of how a use of a checklist was important. If, for example, you just say something like “we have not had a wrong site surgery since we implemented…” you won’t get the same enthusiasm as if you tell a story about how, in a specific case, the checklist actually helped avert a near-miss.
When we’ve seen successful projects using checklists, we always wonder whether success was due to the checklist itself or to the teamwork and culture changes that were involved in implementing the checklist. We suspect the latter are probably as or more important than the checklist. So never be hasty in pushing out checklists. Follow the steps outlined in the toolkit and you’ll likely find that your checklists result in the improvements you were looking for.
Some of our prior columns on checklists:
References:
Roybal J, Tsao K, Rangel S, et al. Surgical Safety Checklists in Children’s Surgery: Surgeons’ Attitudes and Review of the Literature. Pediatr Qual Saf 2018; 3: e108; Published online October 16, 2018
Ariadne Labs/EMIC/Stanford. The Operating Room Emergency Checklist Implementation Toolkit. 2018
https://www.implementingemergencychecklists.org/
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. Implement Sci 2018; 13(1): 50
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-018-0739-4
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November 2018
ECRI Institute has released its Top 10 list for Health Technology Hazards for 2019 (ECRI 2018). Number 1 on the list is the threat of hackers and cybersecurity attacks.
Not surprisingly, two of the Top 10 items pertain to alarm issues. One deals with cases of brain damage or death due to ventilator breathing circuit disconnections during which no alarm activated because alarms were not set appropriately. The other deals with alarm customization that can create opportunities for missed alarms, and thus patient harm, when not handled properly. See our list of our prior columns on alarm-related issues below.
Some old “staples”, such as retained surgical sponges and problems with contaminated endoscopes, remain on the List.
We’re pleased to see that flawed battery charging systems and practices made the list. That was the topic of our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. In that column we provided many examples of battery-related problems that caused patient harm. We stressed that every hospital should have an organized centralized program for battery maintenance and do a full inventory of all your systems that utilize batteries. The sorts of questions you should be asking are:
And if you are using cell phones or pagers for alerting staff to various alarms, consider doing a FMEA (failure mode and effects analysis) and ask not only what would happen if the primary responder’s battery is low but also what would happen if more than one responder’s battery is low.
We also note that battery issues are one of the items you might pay attention to when doing Patient Safety Walk Rounds (see our February 27, 2018 Patient Safety Tip of the Week “Update on Patient Safety Walk Rounds”).
The full ECRI Top 10 List for 2019:
We hope you’ll go to the ECRI site to read all their comments and recommendations on each of the items in their Top 10 List.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
ECRI Institute. 2019 Top 10 Health Technology Hazards. ECRI 2018
https://www.ecri.org/Pages/Top-Ten-Tech-Hazards.aspx
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A disturbing finding in a recent study will make hospitals rethink some of their laundering/cleaning practices. Shek et al. (Shek 2018) assessed microbial burdens on hospital privacy curtains. They found that such curtains, minimally contaminated when first hung, tested positive for MRSA by day 14, and by day21 had MRSA loads that exceeded dangerous levels. The curtains were not in rooms occupied by patients with MRSA. The findings indicate that regular curtain contact that occurs in proximity to an occupied patient bed results in increasing colonization over time. Given that they sampled areas where people hold curtains, the researchers felt it likely that the increasing contamination was because of direct contact. The results suggest that curtains are a source of cross-contamination in hospitals. Because between days 10 and 14 after being hung curtains showed increased MRSA positivity, the authors suggest this may represent an opportune time to intervene, either by cleaning or replacing the curtains.
One might speculate lesser contact with privacy curtains might explain why studies have shown lower rates of some hospital-acquired infections in patients housed in private rooms. Analyzing over a million discharge records in Texas, O’Neill et al. (O’Neill 2018) found that patients who stayed in bay rooms had 64 percent more central line infections than patients who stayed in private rooms. Even after adjusting for relevant covariates, patients assigned to bay rooms had a 21 percent greater relative risk of a central line infection, compared with patients assigned to private rooms. At the hospital level, a 10% increase in private rooms was associated with an 8.6% decrease in central line infections, regardless of individual patients' room assignment.
And a study done in NICU’s (Washam 2018) showed that infants housed in a single-bed unit were associated with a significantly decreased risk of both MRSA and MSSA acquisition compared with infants housed in multibed pods.
That prestigious medical journal, Reader’s Digest, picked up on the Shek study on hospital privacy curtains and extended it to the “10 Things to Never Touch in Hospitals” (Gold 2018). Actually, that article provides links to the medical journals containing the original studies documenting the risks. The 10 items are:
And, of course, items often used by nurses and other healthcare professionals are mobile handheld devices (MHD’s) - tablets and smartphones- that are used to facilitate care documentation and as resource tools. A study at Mary Washington Health care in Fredericksburg,Virginia, sponsored by the Nursing Research Council (NRC), assessed the infection potential of MHDs and possible cleaning methods (Wentz 2018). They found that the mean MHD bioburden before cleaning was 106.8 relative light units (RLUs), indicating bacterial contamination. The mean post-cleaning bioburden was 49.98 RLUs, within the “clean” range. The results indicate that this regimen (70% isopropyl alcohol and 15 seconds of friction) effectively cleans MHDs and decreases the risk of spreading harmful bacteria to patients in the healthcare setting.
Bottom line: cross-contamination occurs frequently wherever healthcare workers come in contact with surfaces or equipment or other objects. Appropriate environmental cleaning at the right time should play a key role in our efforts to reduce hospital-acquired infections.
References:
Shek K, Patidar R, Kohja Z, et al, Rate of contamination of hospital privacy curtains in a burns/plastic war021d: A longitudinal study, American Journal of Infection Control 2018; 46(9): 1019-1021
https://www.ajicjournal.org/article/S0196-6553(18)30155-X/pdf
O’Neill L, Park S-H, Rosinia F. The role of the built environment and private rooms for reducing central line-associated bloodstream infections. PLOS One 2018; Published: July 27, 2018
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201002
Washam MC, Ankrum A, Haberman BE, et al. Risk Factors for Staphylococcus aureus Acquisition in the Neonatal Intensive Care Unit: A Matched Case-Case-Control Study. Infection Control Hospital Epidemiology 2018; 39(1): 46-52
Gold SS. 10 Things to Never Touch in Hospitals. Reader’s Digest 2018;
https://www.rd.com/health/wellness/things-to-never-touch-in-hospitals/
Wentz B, Bowles MJ. Mobile Devices and Healthcare-Associated Infections. Am Nurs Today 2018; 13(9)
https://www.americannursetoday.com/mobile-devices-healthcare-associated-infections/
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A recent story in Oncology Nursing Times (Schulmeister 2018) illustrates one of the hazards of hearing impairment. A cancer patient arrived at busy outpatient registration area. The registration clerk copied his name from his driver’s license to a computer search screen and chose the first name from result list and printed a wristband for the patient. The clerk asked the patient if the information was correct and he nodded “yes” (he was not wearing his glasses). He was then sent to a busy infusion center for his second chemotherapy treatment. There, the nurse asked him if his name is John Doe and if his birthday is the date that she read from his wristband. He nodded yes. He didn’t notice she gave wrong birthday because she had a “heavy accent” and “rattled off numbers” and the infusion room was loud and busy and that he “didn’t hear well.” He received the chemotherapy intended for another patient who had the same name but a different birthdate. There was no apparent harm but a lawsuit ensued anyway.
Obviously, there was a cascade of errors and incorrect practices that contributed to this incident. But we include it here because it does point out yet another problem that the hearing impaired are vulnerable to: patient misidentification. This, by the way, is one of scenarios in which biometrics might have helped considerably in avoiding misidentification.
In our July 2018 What's New in the Patient Safety World column “Hearing Loss and Patient Safety” we noted a study (Lin 2018) that found work- and leisure-related injuries were more prevalent among those with self-perceived hearing difficulty and another study (Simpson 2018) that showed more than 20% higher total healthcare payments among hearing impaired individuals.
Since then, another study has revealed yet another likely vulnerability. Chang et al. (Chang 2018) looked at a representative national sample of patients discharged from hospitals and found that those who reported trouble communicating with their physicians had had 32% greater odds of hospital readmission within 30 days. Their results show we need to raise awareness about the high prevalence of hearing loss among older people and educate staff on how to talk to people with hearing difficulty.
In our July 2018 What's New in the Patient Safety World column “Hearing Loss and Patient Safety” we noted a study (Mahmoudi 2018) which showed the use of hearing aids was associated with reduced probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital.
In an editorial accompanying the Mahmoudi study, Wallhagen (Wallhagen 2018) points out that hearing assessment can be simple and not time consuming. You can use a combination of a simple question and a brief objective test like a finger rub or whisper test, or a brief questionnaire like the Hearing Handicap Inventory for the Elderly. She points out that this takes minimal time and can be scheduled at regular intervals, much like the foot examination for a patient with diabetes.
But, never assume what is heard is actually understood. That emphasizes the concepts of “hear back” and “teach back” which we have stressed in our columns on health literacy and numeracy. (“Hear back” is obviously also critical in communication between healthcare professionals).
It’s time we recognize the high prevalence of hearing impairment and identify it early so that we can ensure we communicate with our patients in a meaningful way that will help avoid some of the unwanted consequences noted above.
Some of our columns on the impact of hearing loss:
References:
Schulmeister L. Cancer Treatment to the Wrong Patient: Why Does This Still Happen? Oncology Nursing News 2018; March 8, 2018
Lin HW, Mahboubi H, Bhattacharyya N. Self-reported Hearing Difficulty and Risk of Accidental Injury in US Adults, 2007 to 2015. JAMA Otolaryngol Head Neck Surg 2018; Published online March 22, 2018
https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2676015
Simpson AN, Simpson KN, Dubno JR. Healthcare Costs for Insured Older U.S. Adults with Hearing Loss. Journal of the American Geriatrics Society 2018; First published: 24 May 2018
https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15425
Chang JE, Weinstein B, Chodosh J, Blustein J. Hospital Readmission Risk for Patients with Self‐Reported Hearing Loss and Communication Trouble. J Am Geriatr Soc 2018; First published: 05 October 2018
https://onlinelibrary.wiley.com/doi/10.1111/jgs.15545
Mahmoudi E, Zazove P, Meade M, et al. Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss. JAMA Otolaryngol Head Neck Surg 2018; Published online April 26, 2018
https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2678187
Wallhagen MI. Hearing Aid Use and Health Care Costs Among Older Adults. JAMA Otolaryngol Head Neck Surg 2018; Published online April 26, 2018
https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2678182?redirect=true
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There have been several recent disturbing reports of iPhones (and some other Apple devices) being wiped out by MRI units.
The story began with a blog on Reddit (u/harritaco 2018a) that said:
“One of our multi-practice facilities is having a new MRI installed and apparently something went wrong when testing the new machine. We received a call near the end of the day from the campus stating that none of their cell phones worked after testing the new MRI. My immediate thought was that the MRI must have emitted some sort of EMP, in which case we could be in a lot of trouble. We're still waiting to hear back from GE as to what happened. This facility is our DR site so my boss and the CTO were freaking out and sent one of us out there to make sure the data center was fully operational. After going out there we discovered that this issue only impacted iOS devices. iPads, iPhones, and Apple Watches were all completely disabled (or destroyed?). Every one of our assets was completely fine. It doesn't surprise me that a massive, powerful, super-conducting electromagnet is capable of doing this. What surprises me is that it is only effecting Apple products. Right now we have about 40 users impacted by this, all of which will be getting shiny new devices tonight. GE claims that the helium is what impacts the iOS devices which makes absolutely no sense to me.”
The issue only impacted iOS devices. Desktops, laptops, general healthcare equipment, and a datacenter were not affected, nor were the many Android phones in the facility at the time. And the Apple models affected were iPhone 6 and higher and Apple Watch series 0 and higher. Some of the devices eventually regained some function over time.
He initially suspected it may have been an EMP (electromagnetic pulse) generated by the MRI machine but, after the posting on Reddit, some others posted and speculated that it might be caused by the liquid helium used to cool the MRI machine. Further investigation revealed that there, indeed, had been release of helium.
He went on to do an experiment (u/harritaco 2018b) where he placed an iPhone 8+ in a sealed bag filled with some helium. After a little more than 8 minutes, the iPhone locked up. After several days it did return to a functioning state.
In an analysis of the event, Wiens (Wiens 2018) notes that the iPhone user guide says “Exposing iPhone to environments having high concentrations of industrial chemicals, including near evaporating liquified gasses such as helium, may damage or impair iPhone functionality. … If your device has been affected and shows signs of not powering on, the device can typically be recovered. Leave the unit unconnected from a charging cable and let it air out for approximately one week. The helium must fully dissipate from the device, and the device battery should fully discharge in the process. After a week, plug your device directly into a power adapter and let it charge for up to one hour. Then the device can be turned on again.” Apparently, the helium inhibits the clock/oscillator that is critical for the iPhone to function.
Since only the newer Apple products were affected, it was postulated that it could be related to Apple's recent switch from quartz components to parts called microelectromechanical system (MEMS) timing oscillators (Casey 2018a).
But the case gets more complicated. Multiple late-model Apple iPhones and Apple Watches were permanently disabled at a Delaware center after it ramped down its MRI magnet (Casey 2018b). Only newer-model Apple products such as the iPhone 8 and iPhone 10 were affected. Those with older models didn't experience any problems, nor did staff with Android phones. Unlike the prior case and though the magnet was ramped down and then back up again, there apparently was no helium release in the Delaware case. Furthermore, whereas many of the devices recovered with time in the prior case, none of the Delaware devices recovered. And, in the Delaware case it was only newer models that had wireless charging capability (hence, no iPhone 6’s) that were affected.
Though some might think the moral of the story is “don’t take your new iPhone or Apple watch near an MRI unit that is being installed or ramped down and up again”, there may also be some patient safety implications. The newer Apple watches are being touted for their ability to record EKG’s and capture bouts of arrhythmias like atrial fibrillation. Such ability could obviously become impaired if the watch fails to function. But, of even more concern, is that we might anticipate future medical equipment and devices might begin to employ microtechnologies like those mentioned above and become susceptible to the same fate as the iOS devices.
So, add this to your list of what can go wrong in the Radiology or MRI suite!
References:
u/harritaco. MRI disabled every iOS device in facility. Reddit 2018; October 8, 2018
https://www.reddit.com/r/sysadmin/comments/9mk2o7/mri_disabled_every_ios_device_in_facility/
u/harritaco. Post-mortem: MRI disables every iOS device in facility. Reddit 2018; October 29, 2018
https://www.reddit.com/r/sysadmin/comments/9si6r9/postmortem_mri_disables_every_ios_device_in/
Wiens K. iPhones are Allergic to Helium. IFIXIT.org 2018; October 30, 2018
https://ifixit.org/blog/11986/iphones-are-allergic-to-helium/
Casey B. Did MRI helium leak take out hospital's iPhones? AuntMinnie.com 2018; October 31, 2018
https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=123398
Casey B. 2nd MRI center reports problems with Apple devices. AuntMinnie.com 2018; November 1, 2018
https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=123411
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Grantham, NH 03753
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btruax