We pointed out in our May 15, 2007
Tip of the Week that important lessons from other industries can be applied in
healthcare regarding patient safety. Accidents in the airline and
transportation industries have many analogies to adverse incidents in
healthcare. Another good example is the 1996 ValuJet fire and crash in the
Everglades (NTSB report).
Basically, the fatal crash followed
a fire in the cargo compartment that was triggered by unexpended chemical oxygen
generator canisters. Such canisters were known to be capable of producing
fires, both because they generate large amounts of heat and then supply oxygen
capable of feeding the fire. Procedures called for not shipping such canisters
unless they had locking caps or their contents had been completely expended.
The major issues had to do with the
nature of the maintencance of planes and problems with communications. ValuJet
was a relatively new airline that was expanding rapidly. One of its cost control
strategies was to outsource some of its plane maintenance, a practice allowed
by the FAA as long as the same policies and procedures were followed by the
subcontractor that would apply to in-house maintenance. The airline outsourcing
is also responsible for oversight and supervision of the subcontractor’s work.
The company doing the outsourced maintenance, SabreTech, also had both its own
full-time maintenance personnel and hired other temporary personnel. The latter
did not receive the same inservice/training on various policies &
procedures that the full-time personnel received. SabreTech also apparently did
not have in stock the locking caps that were required to disable the canisters.
In addition to the financial
pressures that led the airline and the maintenance organization to use
subcontractors and temporary personnel, there was an additional pressure
created by the contractual obligation of the subcontract to turn the airplane
over in a specified time period or face a financial penalty. So some of the
technicians were working extensive overtime in attempt to meet the time
constraints.
They were also functioning in
“multi-operator’ teams, where work begun by one technician might be eventually
completed by another technician. Hence, communication during handoffs was a
problem. In some cases, the “work cards” were signed as though a step (the
expending of the contents) was completed, assuming that someone else had or
would complete that task. And color-coded labels that should have identified the
canisters as hazardous were inappropriately used, resulting in personnel in
shipping/receiving to be unaware they had materials that should not be placed
aboard a plane. And in some cases the only communication that took place with
the shipping/receiving personnel was via those labels. The latter eventually
cleared the canisters to be loaded on the ill-fated airplane.
Additionally, the parent airline
did have supervisory personnel assigned to the subcontractor but they worked
only in the daytime whereas much of the maintenance activities were done at
night.
Sound familiar? Most of these
issues are faced by healthcare facilities on a regular basis. Financial
pressures often lead to use of part-time or temporary personnel rather than full-time
personnel. So one needs to be concerned about proper training/inservicing of
those personnel and ensure that the communications during the resulting
increased number of handoffs will be appropriately managed. In some cases, the
“savings” achieved by use of part-time or temporary personnel may be
short-sighted. Additionally, it is difficult for such temporary personnel to
become part of a “culture of safety” one needs to develop in a healthcare
facility. But if and when you do need to use temporary or part-time personnel,
make sure that they have been appropriately trained for all the procedures in
their area of work.
Teaching facilities also need to
take this into account when housestaff are rotating from one hospital to
another because they are similar to the temporary personnel in that regard.
The color tag issue is also an
important one. In healthcare we often use color coding as a useful patient
safety measure. Nevertheless, everyone needs to understand what the color
coding means. When a facility uses a color code that is not an industry-wide
accepted standard, the “temporary” personnel may not be familiar with it and
may misinterpret its significance.
And the
communications/handoffs/multi-operator team issues abound in healthcare facilities.
And if you are auditing the quality of handoffs in some fashion, make sure you
audit a sample of all handoffs, not just the daytime ones (particularly since
more handoffs probably occur during the evening and night hours).
Once again, lessons learned from
other industries may be extremely valuable in patient safety activities. We’ll
have some other examples in future Tips of the Week.
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