Focus on second-order problem solving, even with defects that have not led to patient harm. 4. How will you know the risk is reduced? Establish metrics that will identify reduction of the defect. These data points can inform staff and patients, as well other stakeholders, about your patient safety efforts, including achievements as well as additional opportunities for improvement. 34 Case Renal Transplant NOTE: Duplicate of slide 29 SAY: In the case study, why did the defect occur? The new resident did not notify the attending anesthesiologist about starting the blood transfusion. There were no mechanisms in place to check the wristband against the Kardex stamp plates. These checks were neither performed in the ICU before the patient left it, nor were they performed in the OR before the surgery began. No redundant systems were in place in this emergent situation to ensure that the documentation matched the patient. The unit environment contributed with near-simultaneous emergent events: the renal transplant patient as well as the craniotomy patient. There were two different groups of providers due to the shift change. There were no independent checks and no proper sign outs between the different providers about the patient. The attending anesthesiologist was not present for the decision to transfuse. Multiple care areas (ICU and OR) along with multiple care teams required clear communication, yet it was unclear if proper handoffs occurred. Patient characteristics also contributed as both patients were of high acuities. Task characteristics also contributed to the defect. The check-in was only as good as the existing identification documents. The resident checked the patient’s identity against the Kardex plate, but not the wristband. Shift changes among staff were not staggered, resulting in a mass change in providers independent of the case status.
Focus on second-order problem solving, even with defects that have not led to patient harm. 4. How will you know the risk is reduced? Establish metrics that will identify reduction of the defect. These data points can inform staff and patients, as well other stakeholders, about your patient safety efforts, including achievements as well as additional opportunities for improvement. Case Renal Transplant NOTE: Duplicate of slide 29 SAY: In the case study, why did the defect occur? The new resident did not notify the attending anesthesiologist about starting the blood transfusion. There were no mechanisms in place to check the wristband against the Kardex stamp plates. These checks were neither performed in the ICU before the patient left it, nor were they performed in the OR before the surgery began. No redundant systems were in place in this emergent situation to ensure that the documentation matched the patient. The unit environment contributed with near-simultaneous emergent events: the renal transplant patient as well as the craniotomy patient. There were two different groups of providers due to the shift change. There were no independent checks and no proper sign outs between the different providers about the patient. The attending anesthesiologist was not present for the decision to transfuse. Multiple care areas (ICU and OR) along with multiple care teams required clear communication, yet it was unclear if proper handoffs occurred. Patient characteristics also contributed as both patients were of high acuities. Task characteristics also contributed to the defect. The check-in was only as good as the existing identification documents. The resident checked the patient’s identity against the Kardex plate, but not the wristband. Shift changes among staff were not staggered, resulting in a mass change in providers independent of the case status. 34
imp_learn_from_defects_facnotes.docx