• human-system interfaces such as provider-device interfaces and microsystem-device interfaces,

• external environment factors such as continuous technological advances, growth and expansion of the organization,

• organizational/social environment factors such as normalization of deviance where shortcuts and shortages may be accepted, or a good provider fallacy where nurses problem-solve and create quick fixes,

• management – limited visibility spent to help identify fallacies in the provision of care process.1

Leaders in healthcare will experience an adverse event in their organization sometime during their career. When they occur, adverse events can be effective avenues to initiate quality improvements.

A root cause analysis (RCA) is an effective way to evaluate adverse events. An RCA utilizes an inter-disciplinary team to review the event and assess where the holes in the "Swiss Cheese Model" occurred. The Swiss Cheese Model of Accident Causation developed by C. Reason is helpful in defining latent conditions and active errors. This model reminds nursing leaders that the nurses are the most susceptible in performing medical errors because they may have inherited the faults of the system.2

During a particular incident involving an adverse event, a potential delay in treatment was identified. This event was reported to the quality division of the organization for review, and an RCA was initiated. An interdisciplinary team reviewed, evaluated and recommended process changes to prevent reoccurrence. Recommendations from the initial RCA assessment were: Staff education and standardization of storage of emergency medical equipment such as ambu-bags, crash carts and defibrillators for easy access; and to increase knowledge of using the equipment effectively. These recommendations were presented and accepted to Corporate Quality and the executive team.

Upon reflection of the analysis, the leadership team believed that there might be more holes in the swiss cheese of emergency care than earlier identified within this large 762- bed tertiary referral and teaching hospital. So, the executive team was charged to assess the entire emergency care process. An inter-disciplinary team was formed to review all aspects of emergency care throughout the organization, including representatives for all disciplines involved with emergency care: Respiratory, nursing, code blue team, emergency response team, biomedical engineering and the central sterile department, etc. A survey of emergency equipment inventory was distributed to all units for an initial assessment of equipment needs and variances.

In the initial meeting, the team reviewed processes and discussed potential gaps in emergency care. The SPD member was integral in identifying the inventory used and the storage location of each crash cart as well as other emergency medical equipment. We also discussed interventions previously identified from the initial RCA and current performance improvement projects occurring throughout the organization. A few areas of improvement were identified:

• Defibrillators being removed from crash carts to transport patients due to inadequate number of transport monitors.

• Multiple models of defibrillators, including obsolete mono- and biphasic models, increasing room for errors with reliance to memory for operation.

• Adequate inventory of biphasic defibrillators would allow for reallocation of one to every patient care unit until all obsolete models could be replaced.

• Staff education was needed to inform of new processes such as storage of emergency medical equipment inventory and use of defibrillators, monophasic and biphasic.

• Multiple equipment quality checklists used throughout the organization decreased efficiency and quality of the safety checks.

At the close of this meeting, the members were asked to complete specific tasks so we could get our recommendations clearly defined at the next meeting. The coordinator agreed to meet with specialty experts to gain further insight and information regarding equipment needs and supplies, including:

• Biomedical engineering manager – developed a purchasing plan focused on removing obsolete equipment and standardization of current and future equipment.

• Vice president of code blue team – identified barriers from the past, involvement of code blue team and discussed standardization of a checklist.

• Administrator of sterile processing department – discussed emergency crash cart inventory and storage.

• Chief nurse of emergency response team – discussed standardization of checklist and practice patterns identified during Emergency Response Team (ERT) rounding.

The project coordinator and the chief nurse of the ERT reviewed all crash cart inventory in the organization. They identified variance in practice and obtained all checklists to ensure that final recommendations would be inclusive of all necessary elements for all units. During their rounds, they educated staff, identified needs for further education as well as collected over 40 different checklists. They identified the need for a waterproof AED for the therapeutic pool area; crash cart access for portable lithotripsy truck; and portable suction in strategic areas for use during transport of critical care patients to intensive care units. Once the rounds were completed, they aggregated their information and formalized a standard checklist for emergency medical equipment to present for all units to use.

The lead team then met with the executive sponsor to review findings and the first version of the standardized checklist. They collaborated with a few units to trial the checklist as a small test of change, incorporating revisions identified by end-users. Initial revisions and variances in practice were presented to the nursing leadership team along with other recommendations noted during rounding in preparation of a Joint Commission visit.

After reviewing the variances, they presented the following recommendations: Standardized storage of defibrillators on top of the crash cart (not on separate cart); ambu-bag storage in every patient room; standardized testing practices utilizing a standard checklist for equipment quality testing. The pilot units that implemented the checklist with success were presented. The council made a few recommendations for the checklist and agreed to adopt this initiative to improve quality of emergency responses. They requested the ERT to provide education for the units and create notebooks with instructions for their unit-specific defibrillator testing to be placed with the checklists on every crash cart.

The interdisciplinary team then met to finalize the plan including a final checklist. They made additional recommendations such as the use of respiratory boards at the head of every patient’s bed to store ambu-bags and other patient-specific airway needs for complex medical patients. Final recommendations regarding staff education, annual competency and chain of custody for emergency medical equipment were developed. This aligned responsibility where education, changes to the checklist or process and acquisition of emergency medical equipment must be approved by the code blue committee to ensure quality and standardization is accomplished.

A final purchasing plan allowed for standardization of defibrillators throughout the organization within the next three years; education for staff; process changes and standardized checklist for all units to follow. Most importantly, through collaboration with appropriate team members, emergency care was redefined and standardized. This initiative resulted in improved daily quality testing, staff education and standard emergency medical equipment, ensuring that emergency care is as efficient and effective as possible. The lead team briefed the organization’s executive leaders on the team’s accomplishments and their recommendations to capital budgeting and purchasing.

To sum it up, adverse events are not welcomed anywhere. However, they can be used to initiate process improvements. Interdisciplinary teams focused on quality and efficiency for the organization are instrumental in identifying all of the holes in the swiss cheese. Working together for the same goal and mission is critical for enhancing quality care for the entire organization.

References:

1. Hughes, R.G. (ed) (2008). Patient Safety and Quality: An evidence-based handbook for Nurses). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; April 2008.