Strong red rules and safety cells cut errors

(Editor's note: This issue includes the second part of a two-part series on how a hospital addressed a wrong-site surgery. Last month, we looked at the details of the event and how the facility responded. This month, we look at what specific changes were made and how the top leader started networking with other CEOs on safety issue.)

I n response to a task force's recommendations following a wrong-site surgical error, Cayuga Medical Center in Ithaca, NY, implemented several changes, including safety cells.

The safety cells are made of groups of caregivers who are responsible for certain patients, such as everyone who works on a particular unit. This safety cell meets regularly, often at the beginning of each day or the change of every shift. Members make sure each person knows about possible safety problems, such as a high-risk medicine being used in the ward or two patients with the same last name. They also discuss any safety breaches that occurred earlier.

"They will go over any issues such as falls that occurred recently, the cause of the fall, and what can be done immediately to prevent any other falls," says David Evelyn, MD, vice president for medical affairs at Cayuga. "The safety cells also go over any issues discovered by other cells, so it becomes a way to quickly communicate any issues and solutions."

Each safety cell sends a representative to serve on the hospital's Safety Council, which meets regularly and includes the risk manager, Evelyn, the infection control manager, the patient safety officer, and other key individuals.

The hospital also implemented these changes:

• Stronger red rules.

Cayuga already used red rules, which are rules that clinicians are expected to follow in all the time, no matter the circumstances. One example is using two forms of identification with each patient for every interaction, such as administering medications or performing procedures. Another is labeling any samples taken from patients at the bedside, before there is a chance to lose or confuse them with another patient's samples. Staff underwent additional training.

"We emphasized the inviolate nature of our red rules," Evelyn says. "Every hospital has lots of policies and procedures, and sometimes you can't follow them because of the situation or it just seems unnecessary in those particular circumstances. We made it clear that these are rules you absolutely cannot violate. There can be no situation, no excuse that will make it OK to violate a red rule at Cayuga Medical Center."

• Tighter enforcement for the Universal Protocol.

Similar to its renewed dedication to red rules, Cayuga emphasizes to clinicians that the Universal Protocol must be followed without exception. The surgical team confirms the patient's name, date of birth, procedure, side the procedure should be on, equipment and supplies needed, position the patient should be in, and any extra safety precautions or allergies. Each team member must affirm each item, with full attention on the time out, before the operation can proceed, Evelyn says.

"If they don't do the Universal Protocol, the procedure is not going to happen," he says. "And we expect every person in that room to object if the protocol is not followed."

• A new patient safety director.

Cayuga leaders determined that the hospital needed a full-time patient safety director and hired Karen Ames, MA, director of performance improvement, to take on the role. Mackenzie says they chose to hire from within because they wanted someone who knew the hospital and its culture.

• A new executive level committee.

Cayuga developed an administrative committee made up of board members, executive level leaders, and administrators, named the Quality and Patient Safety Committee. This committee is charged with overseeing the hospital's patient safety efforts and encouraging a culture of safety. The involvement of the board of directors not only provides the in-house clout to make things happen, but it also signals to the entire organization that the hospital is taking patient safety seriously, Evelyn says.


  • David Evelyn, MD, Vice President for Medical Affairs, Cayuga Medical Center, Ithica, NY. Telephone: (607) 274-4011. E-mail:
  • Rob Mackenzie, MD, CEO, Cayuga Medical Center, Ithaca, NY. Telephone: (607) 274-4011. E-mail:

CEO 'safety huddles' yield ideas for better care

CEO Rob Mackenzie, MD, used his leadership position to help drive the culture change at Cayuga Medical Center in Ithaca, NY.

"I said I wanted to get more education on patient safety and be the flag bearer on this one," Mackenzie says. "I've shared our experience with other hospitals and sought information about their patient safety problems and improvements, and that turned into a CEO patient safety networking group that meets every other month to see what we can do as CEOs to raise this issue to a higher level in our organizations."

One idea that came out of that networking was for Cayuga to have a "safety huddle" for the top directors in the organization at the end of each week that acts in effect as an organizationwide safety cell.

"Just like the cells on the patient care units, we cover any issues we know of throughout the organization and use that meeting as a communication tool," Mackenzie says.