Pulmonary Embolism Due to Delay in Heparin

Một phần của tài liệu Patient safety a case based comprehensive guide springer new york (2014) (Trang 58 - 62)

The medical team on the acute care inpatient service is rounding when the attending is presented an 84-year-old female patient with dementia , hypertension , and obe- sity , who was admitted after a fall and a fractured hip. The attending notes that there are no lower extremity compression devices on the patient and that no order for prophylactic heparin has been written. Given his concern for a deep venous thrombosis in this patient, he asks the intern to place an order for both. The intern decides to wait to place the order at the end of rounds 90 min later. By the time the nurse carries out the order , it is 4 h after the attending has seen the patient. Two hours later a cardiac arrest is called and the patient is found unresponsive. Autopsy reveals a large pulmonary embolus.

Root cause analysis of the case notes the delay in communication between the nurse and the physician as a contributing factor to the event. The hospital addresses this defi ciency by establishing regular interprofessional rounds whereby a nurse on the ward participates in all morning rounds that include the attending.

Discussion

Healthcare’s focus on individual training of physicians and nurses is similar to the aviation industry’s approach more than 25 years ago where the task of fl ying was the responsibility primarily of the pilot. In reality, both the pilot and the

physician accomplish their work as part of a larger team [ 30 ]. Aviation’s approach to expand from the performance of the solo pilot was in recognition that the cock- pit crew should also, with their combined expertise and roles, be responsible for the safety of the passengers. In response, Crew Resource Management (CRM) and similar standardized teamwork models that have been uniformly adopted in the aviation industry to reduce the risk of errors [ 31 ] are fi nding new uses in medicine. In the case of medical care, the care of the patient is recognized as being not only the responsibility of the physician but also of the nurse caring for the patient, the pharmacist preparing the patient’s medications, and other provid- ers of patient care including the social worker and the physical therapist. The Institute of Medicine (IOM) report, “Crossing the Quality Chasm” recommends, among other things, that healthcare organizations implement patient safety pro- grams that “promote team functioning” and that healthcare systems should “train in teams those who are expected to work in teams” [ 32 ]. Other calls for interdis- ciplinary teamwork come from The Joint Commission and the report of the President’s Advisory Committee on Consumer Protection and Quality in the Health Care Industry [ 33 ].

Crew Resource Management

Cockpit or Crew Resource Management (CRM) is a system of team building, communication, and task management used for many years in military and civilian aviation. CRM or similar programs can be defi ned as the effective use of all avail- able resources, people, processes, facilities, equipment, and environment (the cockpit or healthcare environment), by teams (the crew or healthcare team) or indi- viduals to safely and effi ciently accomplish an assigned mission or task. Since the majority of commercial fl ight accidents were caused in part from communication failures among crew members, CRM was designed to standardize communication and teamwork to eliminate critical and fatal errors by the fl ight team. Currently, CRM is required worldwide throughout the aviation industry and is a required aspect of the training of pilots.

The CRM process has been exported to a variety of other industrial settings which share the same characteristics of aviation; settings with high complexity that use advanced technology, work in high stress environments, with an element of danger, have a hierarchal structure, and with major penalties or adverse outcomes for failure. These include diverse industries such as nuclear technology, chemical manufacturing, and health care. The goal of adapting CRM to health care was to increase patient safety and improve clinical outcomes through better communica- tion and teamwork. In the healthcare setting, training in CRM has been associated with major reductions in both observed errors and adverse outcomes. For example, in a study evaluating the effect of implementing the Veterans Health Administration

(VHA) version of CRM, known as Medical Team Training, on patient outcomes, facilities who underwent training had a greater than 50 % decline in surgical mortal- ity compared to facilities that did not undergo training. This reduction in mortality was correlated with a dose–response relationship to the amount of Medical Team Training received [ 34 ].

CRM emphasizes team building, briefi ngs, situational awareness, stress manage- ment, and decision-making strategies. Human factor issues that extend to other team members in joint training also helps to decrease team errors [ 9 ]. CRM Training has been shown to improve attitudes toward fatigue management, team building, com- munication, recognizing adverse events, team decision making, and performance feedback. CRM-trained participants also felt that such training would reduce errors and improve patient safety [ 35 ]. Studies identify several key concepts in CRM that relate to team building. These include managing fatigue and workload; stress man- agement, creating and managing the team, recognizing adverse situations, cross- checking, and communicating; and assertiveness, developing and applying shared mental models for decision making, situational awareness, and giving and receiving performance feedback [ 36 ].

The Team STEPPS approach

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a systematic approach developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice. It is designed to improve the quality and safety as well as the effi ciency of health care. TeamSTEPPS is based on research related to team- work, team training, and culture change. The components of TeamSTEPPS are based on a list of competencies developed by Baker as important elements of team- work in the professional education of physicians [ 37 ].

Figure 2.2 illustrates the critical concepts related to the teamwork training approach in TeamSTEPPS [ 38 ]. Individuals earn four primary trainable teamwork skills: leadership, communication, situation monitoring, and mutual support. By building a fundamental level of competency in each of those skills, research has shown that the team can enhance three types of teamwork outcomes: performance, knowledge, attitudes. Table 2.2 lists the components of the TeamSTEPPS curricu- lum. These include the barriers that undermine the team and its effectiveness as well the tools and strategies to overcome them. Outcomes from TeamSTEPPS include intermediate process-level outcomes such as a shared mental model and mutual trust as well as improved patient outcomes and patient safety.

Table 2.2 Components of the TeamSTEPPS curriculum.

Barriers Tools and Strategies Outcomes

Inconsistency in team membership Lack of time

Lack of information sharing Hierarchy

Defensiveness Conventional thinking Complacency

Varying communication Styles Confl ict

Lack of coordination and follow-up with co-workers

Distractions Fatigue Workload

Misinterpretation of cues Lack of role clarity

Brief Huddle Debrief STEP1

Cross Monitoring Feedback

Advocacy and Assertion Two Challenge Rule CUS 2

DESC Script 3 Collaboration SBAR 4 Call-Out Check-Back Handoff

Shared Mental Model Adaptability Team Orientation Mutual Trust Team Performance Patient Safety

1STEP: Status of the Patient, Team Members, Environment, Status toward goal

2CUS stands for “I’m concerned, I’m uncomfortable, this is unsafe, or I’m scared”

3DESC Script Model:

1. Describe the actions or behavior that you see as taking place;

2. Express why that behavior is an issue?

3. Specify the resulting actions or change of behavior you would like to effect;

4. Clarify the consequences for failing to change behavior or meet demands.

4SBAR: Situation, Background, Assessment, and Recommendation Fig. 2.2 The TeamSTEPPS

conceptual framework.

Adapted with permission from “Barriers to Team Effectiveness” in

TeamSTEPPS ® Fundamentals Course: Module 7.

Summary—Putting It All Together (Instructor’s Materials)

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