Alert system helps stop error before it harms
At Virginia Mason Medical Center (VMMC) in Seattle, staff are not only encouraged to speak up when they see errors or deficiencies that could harm a patient, they are required to do so. A patient safety alert (PSA) system obligates anyone seeing a dangerous situation to report it immediately, which then prompts an investigation.
The hospital is reporting excellent results from the system, and one expert says it is a good example of how empowerment of employees all the way down the line can improve patient safety.
Cathie Furman, RN, MHA, senior vice president of quality and compliance, explains that the system requires all employees to immediately "stop the line" by halting any activity that could cause further harm to the patient. The term "stop the line," derives from the automobile assembly line because the philosophy behind the VMMC system began in that industry.
Once the employee reports the problem, a patient safety specialist responds, and if he or she decides patient safety is at risk, an investigation is immediately launched. Since the system was first implemented in 2002, patient safety has improved, and the number of medical malpractice claims has dropped, Furman says.
In a published report on the system, Furman provided this description of how the system works:1
Staff members report problems using a 24-hour hotline or an online reporting system. The reports are known as PSAs.
Five patient safety specialists monitor the hotline, and at least one specialist is available 24 hours a day.
PSAs are ranked according to likelihood of patient harm and recurrence. Red PSAs are those that have caused or can cause serious harm, as well as those that have the potential to occur frequently. These require an immediate investigation and resolution within 24 hours.
Orange PSAs are less likely to cause harm or recur. They must be investigated and resolved within 72 hours. Yellow PSAs are the least likely to harm patients and must be resolved within a week.
When an employee reports a red PSA, the patient safety specialist contacts the senior executive or the administrator on call after business hours. That person helps coordinate the investigation in cooperation with the relevant supervisor, such as the chief of surgery or pharmacy director. The executive goes to where the problem was reported and decides whether the people involved should be removed from the work force, either temporarily or permanently.
VMMC provides these examples of how the PSA system led to improvements in patient safety:
When an illegible pharmacy order was misinterpreted by both a pharmacist and a nurse, leading to patient harm, the medical center developed a new protocol that outlines each group's required response if a dangerous abbreviation is used.
A patient received a color-coded wristband on admission signifying "do not resuscitate" instead of the correct one indicating drug allergies. The error was traced to a nurse being colorblind. To prevent a recurrence, the medical center added words to the colored wristbands.
An oncologist was placed on administrative leave and temporarily lost his privileges to admit patients to the medical center after berating a nurse who refused to start a patient's chemotherapy without first obtaining necessary test results.
The VMMC experience with the PSA system is a perfect example of how well employee empowerment can improve patient safety, says Steve Spear, PhD, senior lecturer at Massachusetts Institute of Technology and a senior fellow at the Institute for Healthcare Improvement, both in Cambridge. Spear is the author of Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win (McGraw-Hill; 2008).
The PSA system is an example of how health care systems can manage complex systems with the same philosophy that has been successful in other industries, i.e., the idea that you must empower those at the lowest levels to do what is right for the customer and the organization, Spear says.
"A key part of what they're doing at VMMC is telling everyone that it's not just about having the right to report a problem. It's not just that it's OK to report their concerns and they won't get in trouble for it," he says. "The alert system is predicated on the idea that employees have an obligation to report, that they are expected to report it, and do whatever is necessary to stop the patient harm right away."
Spear notes that the VMMC system involves extensive commitment and involvement from senior executives.
"The result is better care at less cost, and that is an exciting proposition for any health care organization," Spear says.
Reference
1. Furman C, Caplan R. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf 2007; 33:376-386.
At Virginia Mason Medical Center (VMMC) in Seattle, staff are not only encouraged to speak up when they see errors or deficiencies that could harm a patient, they are required to do so. A patient safety alert (PSA) system obligates anyone seeing a dangerous situation to report it immediately, which then prompts an investigation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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