What is one of the common reasons why the following events occur?
- In a recent NBA game, an All-Star point guard was consistently lighting up the other team from outside the three-point line. The next time down, instead of taking a shot from beyond the arc, he rocketed a pass to his veteran teammate, who was not ready for the ball. The ball flew off his hands and resulted in a turnover to the other team.
- During a recent NFL game, an experienced running back went to the left of the star quarterback, when the quarterback turned to his right for a handoff. The two missed each other, fumbled the football, and the opponent recovered the ball.
- Recently, a physician was taking care of the typical laundry list of tasks for his service. While documenting a note in Epic, he took a call about putting in orders for a patient. Inadvertently, he placed the order into a different patient's chart that was already open, resulting in a medication ordering error.
- A patient needed a procedure that the team had done only a couple of times together. Lots of assumptions were made regarding the procedure and it was unclear who was responsible for taking care of paperwork and the setup. As a result, the patient had the procedure performed on the wrong site on the body.
In all four of the above situations, no one died (thank goodness), but there were repercussions associated with each of them. In the first two, it involved winning or losing a game. In the last two, it involved additional hospital care, cost, time and energy to investigate the events.
There are multiple root causes and contributing factors to why these situations occurred. But one thing was missing in each scenario—single mindedness. In sports, it's often referred to as "being on the same page." Each situation had internal and external dynamics such as production pressure (clock is running), environmental hazards (noise), fatigue, distraction, missing or lack of information and assumptions. And despite these influences, things go exactly as planned 99 percent of the time. But when they don't, each of these items contributes to the outcome.
Take a time out
A known, tested and proven strategy to re-engage "single mindedness" is the time out. In sports, the time out is used to quickly check to make sure the team is on the same page. In health care, the concept is identical. Taking a "time out" gives you a moment to make sure that the treatment team has the same focus, the same objective and the same goal.
At a minimum, the procedural time out consists of ensuring three elements:
- Right patient
- Right procedure
- Right location (addressing laterality)
These three elements are the bare minimum of the Joint Commission's time out requirement. Pausing and confirming these three elements, depending on the number of procedures being done and where, only takes about 20 seconds the majority of the time. That's not much of an investment compared to spending dozens and dozens of non-productive hours in an investigation, with interviews, depositions, hearings, or if a truly bad outcome occurs, a court trial.
The three-part time out process is considered "standard work," a concept promoted by the Stanford Operating System (SOS). Under the concept of the SOS Management System, this standard is no different than making sure that you document a daily progress note, sign off your orders or examine the patient before you prescribe any medications. Safe patient care means no errors. Safe patient care is part of quality care. Thank you for doing your part!
If you have a patient safety story to share or questions about SHC's patient safety program, contact Steve Chinn at firstname.lastname@example.org or (650) 723-6395.