CUSP: Principles of Safe Design Apply to Technical and Teamwork OutcomesOn October 14, 2019 by Raul Dinwiddie
>>Peter: The next principle we want you to understand is that those ideas of designing safe systems: standardizing work, creating independent checks, and learning from mistakes, don’t just apply to our technical work, they also apply to our teamwork.>>Whenever we’re sending a message, the sender encodes meaning, that is, they may use ambiguous language, they may have nonverbal language, and we all do this to make it efficient. That message passes through an environment, which in healthcare is noisy and chaotic, and the message goes to a receiver, who may be doing something else, they may be drawing up a medicine, they may be checking in a patient. And that receiver has to decode that message, that is, try to determine what was the intent of the sender. Anywhere along this continuum, errors could occur, and we could defend against those by applying the principles of safe design. The sender of the message could standardize how they communicate, terms like SBAR and Briefings, and Daily Goals, are nothing more than standardizing that input. And the receiver could reduce the risk of a decoding error, of a translation error, by reading back, by creating an independent check to say, this is what I understood you to mean, is that correct? The nurses who I work with all the time, if I use vague language, which, unfortunately, I often do, will say, “Peter, you’re making me decode, please be more specific.” And they’re spot on, we need to. And when communication errors occur, we need to learn from our mistakes. That is, we need to pull together and reflect on what happened? Why did it happen? What could we do differently? And, how do we know that care is actually better?>>One of the tools that could help improve communication and teamwork is the daily goals. The idea comes from management. We know that individuals and organizations that set goals and get feedback toward those goals, accomplish much more than those who don’t. And yet too often, we don’t apply goals to patient care, even though being in the hospital poses risks. Let me share with you a story of how it was applied. I made rounds with a team on a patient that had heart failure. The doctors concluded with a plan that said, Let’s convert the IV anti-hypertensive medicine to PO. Let’s diurese the patient, and let’s try to wean their oxygen. And they walked away saying, we make rounds just fine, those are clear goals. And I asked them, “well what were your goals yesterday?” The patient had been in the ICU for three days now. And they said, “well, they were to wean the anti-hypertensive, to diurese them and get the oxygen down.” I said, “how did you do? Well, not so well, I guess, the patient was positive three liters and they’re still on IV anti-hypertensive. I said, “what if we applied this daily goal principles of being very specific about what our plan is? What might it look like?” Well instead of saying, wean the anti-hypertensive, it would be, give them 100 of a PO medication right now, and if they’re not off the IV drugs by noon, let me know and we’ll double the dose. Give them a diuretic now, and if we’re not a third of the way towards three liters of our fluid goal, then let’s increase that dose, and let’s wean the oxygen as the water comes off the patient. The nurses said, “boy, I would love that degree of clarity.” The doctors said, “well that’s a much more specific way of managing it.” Three months later, that ICU cut three days off their length of stay by rigorously applying the daily goals.>>Sidney: Usually in a crisis, no matter how well trained physicians and nurses are, in the heat of the battle, when things are going south, you kind of lose your train of thought. Our CUSP team actually came up with a check off list for a postpartum hemorrhage protocol, which I had the experience of actually putting it into practice about two weeks after we developed it. I actually had a patient who experienced a significant hemorrhage event, and the nurses promptly went to the protocol – started going through the medications, the check list, and it worked amazingly well. And the outcome of the case was exactly what we expected. We saved the patient’s life.>>Patricia: One thing that we learned early on, was to be transparent. It used to be that you would take your defects, you would take whatever error occurred, and you’d shove it in a closet. In order to actually advocate for patient safety, we had to deal with the emotions that the defects created. We’re very transparent, when there is an adverse event, or a near miss, we do debriefings with the team involved, we do debriefings with the entire staff, because there’s a ripple effect. If I had an adverse event, it’s going to affect my coworker.>>Ann: You really want to be able to learn from what happened. And typically we go through a root cause analysis and we look at, step-by-step, what happened? And then we address the process. What can we do so that this will not happen again? And you look at everything, put an action plan together, work with the staff in rolling that out. And you want the team involved in that.>>Peter: Poor teamwork is the major contributing factor to patient harm in healthcare. It not only harms patients. It frustrates us. It reduces our joy in our work. And it adds unnecessary cost to care. These principles of the science of safety could help you improve teamwork. Undoubtedly patient safety will improve, and I guarantee you, your joy in work will improve.