More About Patient Safety
What do timeouts prior to an invasive procedure, a hand washing protocol, and annual TB tests linked to credentials have in common with a preflight cockpit checklist?
All four protocols save lives.
I’m using an airline safety analogy as I’ve done in the past at least in part because aircraft checklists and related procedures are understandable and have been proven over many years to improve safety. Parallel procedures in the medical environment are more recent, and like many new things, sometimes make us feel defensive when we’re told to implement them.
We surgeons in the operating room are now accustomed along with our nursing and other professional colleagues to use the Universal Protocol intended to make sure the right procedure is being performed on the right patient in the right location (site). The protocol is explicit. We have a preoperative verification process — patients don’t go to the OR until the surgical consent is in the chart and the patient has marked the surgical site. Then before the first cut, we have a “time out,” when the surgeon, anesthesiologist and nurses all stop work to verify and agree that the patient procedure and site match the written consent form and the surgical schedule. The boarding pass is used to document the Universal Protocol. (see Boarding Pass.pdf)
The Universal Protocol is becoming second nature in the operating room, but we learned through our mock Joint Commission site visit earlier this year that we have some work to do. The protocol applies throughout the organization, including the cath labs, endoscopy suites, or for that matter, any nursing unit or outpatient department where invasive procedures are performed. The Joint Commission requires uniform standards throughout the organization. For example, Norm Rizk, medical director of intensive care units, notes for bronchoscopies that “doing the boarding pass procedure [Universal Protocol] assures all of us that we know the indication, the plan, and the expected outcome. It also establishes a team ethos in proceeding, and acknowledges that we are doing this specifically for an individual patient’s particular needs.”
All of us involved with invasive procedures in our medical center need to make sure a “time out” and use of the boarding pass are second nature. This represents a change of culture — the creation of a team ethos and a shared recognition that a disciplined process is in the best interest of our patients. As many of you know, we are finding equitable ways to monitor compliance with Universal Protocols throughout the medical center, just as we have successfully done in the operating rooms.
Another area where we need to be rigorous about following a safety protocol involves hand hygiene. And please don’t let the prosaic sound of this function mask its importance. Forget what mom told you about washing your hands — then again, don’t.
It does not take much effort for everyone to use the alcohol-based hand sanitizer dispensers the hospital has gone to great lengths to place outside and inside every patient room. Let’s popularize the phrase “gel in and gel out” so that it will become second nature for all of us.
A demonstration of the gel recently made believers of Medical Board members after they were asked to place their hands on a Petri dish plate. I believe many physicians were shocked to see the growth of microbial organisms from their unwashed hands. Many of my colleagues may also have been surprised to see just how using good hand hygiene — applying the alcohol gel — left a much cleaner Petri dish plate.
Here’s what it looked like:
Next, I want to note that we have work to do concerning the mandated annual tuberculosis test. Some recent history is in order. In the past the hospital used a database to remind physicians when it was time to go for their two-step annual tuberculin test, which is a regulatory requirement and a patient safety tool. Each of us would go to Occupational Health, have the skin test placed and then return two days later to have the test read. (Alternatively, we could fax in the result if read elsewhere.)
The system stopped functioning effectively for a number of reasons over the past several years, and I would bet most of you can’t recall the last time you had a tuberculin test performed. But I am happy to report that making our patients safer has gotten easier. We now have the ability to offer the QuantiFERON Gold TB test, approved by the FDA in 2005, which requires only a single annual blood draw and detects Mycobacterium tuberculosis infection, including latent tuberculosis infection (LTBI) and tuberculosis (TB) disease. No longer will you need to have a skin test read. As a bonus, the Occupational Health and Safety Department will be able to check on your immunity to varicella, rubella, rubeola, and Hepatitis B with this single blood draw as well. We are hoping to have this test process facilitated so that medical staff will be sent the laboratory requisition annually as a reminder to go in for a one-stop test.
All of these elements involve good practice as well as vital patient and personal safety. But if your enthusiasm or dedication still isn’t up there, just picture the captain of your next flight and wonder if he or she has gone through the checklist. And if you need even further encouragement, please remember, we will be visited — unannounced — by the Joint Commission in 2007. Let’s be ready for Joint Commission — and for our patients!
Lastly, I wish to extend to all of you and yours best wishes for a Happy Holiday Season and a very Happy New Year!