Sara Atwell, RN, MHA, Oakwood Healthcare System - Speaker at the marcus evans National Healthcare CNO Summit 2012, held in Hollywood, FL, April 26-27, 2012, delivered her presentation entitled Stop the Line – Empowering Clinicians to Recognize and Act on Impending Adverse Events

1. Sara Atwell, BSN, MHA
Chief Quality and Patient Safety Officer
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Oakwood Healthcare System
CNO Symposium
April 26 & 27, 2012

2. “Our Systems are too complex
to expect merely
extraordinary people to
perform perfectly 100% of
the time. We, as leaders,
have a responsibility to put
into place systems to
support safe practice ”
practice.
James Conway, IHI Senior Fellow

3. 44,000 to 98,000 deaths annually in the US
from medical errors (IOM 1999)
Equivalent to 2 – 747’s crashing every week
747 s
CDC estimates that hospital-acquired infections
alone kill 99 000 people each year
99,000
More people die each year in the US as a result of medical
errors than from AIDS and breast cancer combined.
This terrible outcome is the equivalent number of lives
that would be lost if a Boeing 767 full of p
g passengers
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crashed every day of the year.

4. The IOM report is serious business and p
p providers
are responding.
Every unnecessary death in your healthcare
system is unacceptable. Y t many such d th occur
t i t bl Yet h deaths
The problem is urgent ; we cannot turn a blind eye to
it while conducting business as usual
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Leadership is needed to change culture behaviors,
and processes that allow medical errors to happen.
Caregivers must be given the tools to identify
impending events and be empowered to STOP them
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from occurring.
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5. From the Eyes and Ears of the
Nurses:
Time Pressures - high census, high acuity more
patients than they can adequately manage.
Team work is poor - morale low , burn out high
Increase in administrative tasks take nurses
away from the bedside.

6. From the Eyes and Ears of the Nurses:
Mounting C f
Confusion
Look alike sound alike Medications , similar
packaging
Different equipment same use
Physician p
y preference - Individual vs . system
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processes
Behaviors inconsistent with safe culture
Administrator complacency
Arrogant and disruptive behavior
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7. “Our Systems are too complex
to expect merely
extraordinary people to
perform perfectly 100% of
the time. We, as leaders,
have a responsibility to put
into place systems to
support safe practice.”
practice.
James Conway, IHI Senior Fellow

8. Make
Decisions
D i i
Communicate
Recognize
Adverse situations
Create a Team
Manage Fatigue

9. What i
Wh t is an “Adverse Sit ti “
“Ad Situation
A situation where events are
leading to an undesirable outcome
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These situations are normally indicted by
Warning Signs

10. No IV - central line pulled
Eyes rolling back
15% weight loss
Not listening to family’s concern
Unusual pt behavior
Nurse appeared hurried, nervous,
“odd”
Methadone administered after “No
narcotics” verbal order

11. • 7 errors per neonatal
arterial switch
operations (de Leval
et al 00)
• 8.8 team errors per
ED malpractice case
(
(Riser et al 99)
)
• 4 errors
precede/coincide
with every medical
accident (Reason)97)

12. “ among all types of medical errors, cases in
which the wrong patient undergoes an invasive
procedure are sufficiently di t
d ffi i tl distressing to
i t
warrant special attention. After examining the
case of a patient who was mistakenly taken for
another patient’s invasive electrophysiology
p
procedure and the results of the institution’s
root cause analysis the team members
discovered at least 17 distinct errors, no single
one of which could h
f hi h ld have caused this adverse
d hi d
event by itself.
Mark Chassin MD, MPP, MPH and Elise c. Becher MD, MA
, , ,

13. Case
Study

14. A warning sign to tell you that an adverse
situation may be developing
Prepares Team members to take action to
p
prevent an unwanted outcome

15. Conflicting
C fli ti Failure t meet
F il to t
inputs targets
Preoccupation Not addressing
discrepancies
Not
communicating
Fatigue
Confusion
C f i
Stress
Violating policy
or procedures

16. “Red Flags
Red Flags”
“Heads‐up”
“H d ”
“Probable adverse situation”

17. See It
Be able to recognize Red Flags
If you see one – l k for others
look f h
Say It
Communicate what you see
Fi It
Fix
Take action or “Huddle” as appropriate

18. See it
Say it
Fix it

19. Communication
Communication
Communication

20. The greatest problem in communication
Is the illusion that it has been
accomplished.
It is the critical factor in delivering good
healthcare

21. A factor in
in…
•80% of adverse events/close-calls
(VA N ti
National C t f P ti t S f t E
l Center for Patient Safety Executive S
ti Summary, 2007)
•66% of sentinel events
(Joint Commission Sentinel Event Alert - Issue 12)
•50% of OR errors (Gawande et al, 2003)
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•30% of OB/GYN adverse events (White et al, 2005)

22. Assertive
Aggressive
Passive or Passive Aggressive
Passive or Passive Aggressive

23. The goal is to dominate and win
“This is what I think, what you think does not
matter‐you are uniformed”
tt if d”
Often expression of feelings, thoughts in a
way that is not wholly truthful
Usually done in an inappropriate and
unprofessional manner
Body language‐clenched fists, crossed arms,
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glaring eyes, intrusive on personal space

24. How does an aggressive
How does an aggressive
Communication style impact
patient safety?

25. The goal is to appease and avoid conflict at all
The goal is to appease and avoid conflict at all
costs
Fail to express your thoughts/opinions
Sarcastic
Give in with resentment
Remain silent
Body language The Victim Stance
Body language – “The Victim Stance”

26. How does a passive
communication style impact
communication style impact
patient safety?

27. Assertiveness is an attitude and a way of
positively relating to those around you;
positively relating to those around you;
skill set for effective communication
includes:
includes:
See yourself as having worth
See yourself as having “worth”
You value others equally, respecting their right
to an opinion.
to an opinion.
Engage in communication respectfully, while
also respecting your own opinions.
p gy p

28. Being appropriately assertive means:
Organized in thought and communication
Speak clearly, and audibly
Owned by the entire team (not just a
“subordinate” skill‐set, and it must be valued by
the receiver to work)
the receiver to work)
Seeking clarification/common understanding
Seeking clarification/common understanding

29. Saying “yes” when indicated, but “no” when you
mean “no”
mean “no”
Using “I” when not speaking for the team.
U i “I” h t ki f th t
Respectively defending your position, even if
R i l d f di ii if
it provokes conflict.
Body language – Secure upright position in a
relaxed manner, making eye contact, standing
relaxed manner making eye contact standing
with open hands.

30. Aggressive
A i
Hostile
Confrontational
Ambiguous
Demeaning
Condescending
Selfish

31. Focus on the common goal: Patient safety, quality
of care – who can disagree with this?
Avoid the issue of who’s right and who’s wrong
(check your ego at the door it is not about you, it
(check your ego at the door – it is not about you it
is about the patient).
De‐personalize the conversation.
l h
Actively avoid being perceived as judgmental.
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Be hard on the problem, not the people.

32. NAMES FIRST – Get their attention
Make EYE Contact
Make EYE Contact
Express your concern
State the issue (clean, concise)
St t th i ( l i )
Propose action(s)
Re‐assert as necessary
Agree on a course of action
Agree on a course of action
Escalate up the chain of command if no
resolution – remember, it is about the
resolution – remember it is about the
patient

33. Assertive Statement
Get attention → Call them by name
Express concern
E → “I am concerned”
State the problem → Brief objective & clear
Brief,
Propose a solution → “We” or “Let’s”

34. Assertive
No response? Statement
No response? Add “Check”
Relay Info

35. Nurse Danner: Nurse Danner: “Doctor
“Doctor, we don’t
Doctor, don t Smith, I’m concerned we
have the wrong patient.
h h i
have a patient We don’t have a patient
named Morris on named Morris on the
the schedule. I’m schedule but we do have
h d l b d h
concerned there a Morrison. Let’s check
her chart and call the
might be a mix-up.”
i ht b i ” floor to see if we h
fl f have
Doctor: “This is our the right patient before
we proceed.”
p
patient.
patient ”

36. Get A
Decision
Assertive
No response? Statement
N ?
No response? Add “Check”
“Ch k”
Start at any Block
Relay Info
based on criticality
b d iti lit
of situation

37. Assertive
Statement
Get attention → Call them by name
Express concern
E → “I am concerned”
State the problem → Brief objective & clear
Brief,
Propose a solution → “We” or “Let’s”

39. Front Line
EXAMPLES

40. A patient is crying, clearly upset and
A ti t i i l l t d
uncomfortable. The patient’s caregiver,
Sue, is talking and laughing on the phone,
S i t lki d l hi th h
clearly on a personal call, and you believe
she is ignoring the patient.
h i i i th ti t
What would an assertive statement sound
like?

41. Sue, I am concerned. Your patient is
upset and needs some attention.
upset and needs some attention
Let’s see what we can do for her.

42. An interventional room is undergoing
construction, so the physician decides to
construction, so the physician decides to
perform a case in the OR, despite having
been asked not to by the Charge RN, due
been asked not to by the Charge RN, due
to staffing/equipment availability. The
doctor tells the RN to take the patient to
doctor tells the RN to take the patient to
the OR and the rest of the team can
“catch up”.
catch up .

43. Dr., I am concerned that we will not
have the things we need to safely
have the things we need to safely
care for the patient. Let’s discuss this
further and get everything into place.
further and get everything into place

44. The new work schedule has just been
Th k h d l h j b
posted. Your co‐worker, Nancy, is
unhappy with her assignments and
p
proceeds to disparage the manager
p g g
and the schedule in front of patients
and families.
and families

45. Nancy, I am concerned that your
comments may send the wrong
comments may send the wrong
message to our patients and families.
Let s take this discussion to a private
Let’s take this discussion to a private
area.

46. You are relieving another RN, Anita,
You are relieving another RN Anita
for lunch in the middle of a
procedure. There are specimens on
d Th i
the field that have not yet been
identified or labeled. Anita gives
report, states she is “very hungry”
p , y gy
and that you should be able to
handle the specimens.
handle the specimens

47. Anita, I am concerned that
there’s a big potential for error
th ’ bi t ti l f
here. Let’s label and verify the
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specimens together before you
go.
go

48. The PACU RN notes a developing
hematoma after a carotid procedure,
and informs the physician. The
physician states “why are you calling
me? The nurses at the other
hospitals never call me for this. I am
not coming there now.”
What would you say in response?
What would you say in response?

49. Dr., I am concerned that this
hematoma may compromise
h t i
y
your patient’s airway. Let’s
p y
discuss our plan of action.

50. Each and everyone of us are
responsible for our individual
p
contributions to the team.
And our teams will only be as
And our teams will only be as
successful as our individual
contributions to the team allow.

51. What is your personal
Wh t i l
commitment?
Recognition and thank you to LifeWings Partners LLC