Spotlight Case December 2005

1. Spotlight Case December 2005 Low on the Totem Pole

2. Source and Credits • This presentation is based on the Dec. 2005 Spotlight Case in Surgery/Anesthesia • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Robert Wachter, MD, UCSF School of Medicine • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the concept of authority gradient • List steps that can be taken to increase communication across an authority gradient • Consider the current culture of safety in your own institution

4. Case: Low on the Totem Pole A fourth-year medical student on rotation in the Pediatric Intensive Care Unit (PICU) observed the operative repair of a congenital heart lesion. When the student arrived in the OR, the patient was already intubated and anesthetized, and procedures were underway to prep the patient for surgery.

5. Case: Low on the Totem Pole The student observed one of the team members insert a Foley catheter into the female patient. He was surprised to see no efforts were made to perform “sterile prep” prior to insertion. Being new to this setting and assuming different practices were used in pediatric patients, the student dismissed the incident, and did not mention it to anyone in the OR.

6. Authority Gradients • Health care is unique in its interdependence across personnel • Attending, resident, students, nurses, respiratory therapists, clinical pharmacists, clerks, etc. • Communication between these groups, given differences in levels of authority, can be challenging

7. Barriers to Raising Safety Concerns:the Medical Student Perspective • Medical students are neither in authority nor an authority, and are low on the totem pole • Nurses, therapists, pharmacists, and MDs all have more experience than they • Concerns may be unfounded/wrong • “Maybe this procedure does not require aseptic technique”

8. Barriers to Raising Safety Concerns:the Medical Student Perspective • Systems do not exist to facilitate this communication • Lack of emphasis on incident reporting system • Authority gradient is massive • Trainees are being evaluated by their superiors • Culture may not be supportive even if student comes forward

9. Case (cont.): Low on the Totem Pole On postoperative day 3, the student found that the patient had been febrile overnight and urine culture had grown Pseudomonas aeruginosa. On rounds, the student presented this new data, including the account of the Foley placement in the OR. The patient’s Foley catheter was discontinued and appropriate antibiotic coverage provided.

10. Case (cont.): Low on the Totem Pole After rounds, two attendings approached the student, separately. One remarked that the information about the catheter should not have been presented on rounds due to concerns that family members might overhear. The second attending said this information should have been conveyed at the time of the incident. Neither attending commended the student for reporting the incident to the team.

11. Teamwork Survey • “Junior team members should not question the decisions made by senior team members” • Airline pilots—nearly unanimously disagree with this statement; they would want to be questioned directly if coworker thought something was wrong • Surgeons—nearly half said they would not want coworkers to raise safety concerns during surgery Sexton J. BMJ. 2000;320:745-749.

12. Teamwork level rated as “high” Sexton J. BMJ. 2000;320:745-749.

13. Crew Resource Management in Aviation • Developed as a result of several tragedies due to failure of communication • Encourages discussion across authority gradient • Simulation exercises demonstrate the importance of unspoken communication creating a culture that promotes safety Hamman WR. Qual Saf Health Care. 2004;13:i72-i79..

14. Creating a Safe Environment • Establish clear protocol for reporting incidents • Provide teamwork specific training • Create the expectation that it is necessary to “stop the presses” when someone witnesses a potential error • Resist “production pressure” • Measure culture of safety using validated tool Morey JC, et al. Health Serv Res. 2002;37:1553-1581.

15. Survey toolclick here

16. Test Your Own Institution • If a ward clerk in your institution caused a 20-minute delay in the OR schedule to confirm that a patient had truly consented to a procedure (and it turned out the patient had consented), would she: A. Be rewarded for her efforts B. Be labeled as “difficult”

17. Case (cont.): Low on the Totem Pole Shortly after this incident, the student submitted a report outlining the events in the OR to the institutional patient safety office.

18. Take-Home Points • Authority gradients exist in health care • All health care workers must learn to foster communication across this gradient • Institutions must create an expectation of immediate reporting of possible errors • Health care workers must not allow production pressure to interfere with safety