Memorial Hermann Health System in Houston adopted several programs to promote high reliability among its employees. The following are four of the most successful initiatives:
• STAR: Employees are encouraged to Stop, Think, Act, and Review. Research has shown that the chance of an error decreases logarithmically with the amount of time spent in thought before taking an action, notes Chief Medical Officer M. Michael Shabot, MD, FACS, FCCM, FACMI, at Memorial Hermann. The health system encourages healthcare providers to stop for one second.
“It’s not like on TV where the doctor barks out an order, the nurse(s) measures out the injection and plunges it in,” he explains. “We take a one second stop before the patient gets the med, so the nurse can ask if this is the right patient, right dose, right medication. We have hundreds of patient safety reports in which a patient was saved from harm by that one second stop.”
In one case, a neonatal intensive care unit nurse had a proper computerized order for a medication, went to the pharmacy where it was entered into the computerized dispensing machine, and took the med back to the unit. She did a one second stop and realized that although all of the outer packaging was marked for pediatric use, the actual vial of medication inside was the adult concentration of the drug, which would have killed the child.
• CUSS words: Physicians and staff are trained to use particular phrases when they are concerned, and to respond appropriately when they hear those phrases. They were crafted to be specific, easily recognizable statements that raise a red flag to other clinicians but which can be said in front of patients and family members without causing alarm. They are:
- I am Concerned.
- I am Uncomfortable.
- This is for Safety.
In addition, the final S comes from the promise to “Stand up and stand together” when a colleague raises a concern. Memorial Hermann staff are assured that raising a concern in this way will never result in discipline or any negative consequences, no matter who is objecting or disagreeing. “They are absolutely backed up, and when someone speaks up for safety we bring them into the boardroom to tell us about it and so we can honor them for their actions,” Shabot says. “Even if they turn out to be wrong, they are honored for speaking up.” Two nurses recently told the board about how they were worried that a patient had a pulmonary embolism after surgery, but the attending physician disagreed. They took their concerns to the surgeon who performed the procedure, who determined that the patient did not have a pulmonary embolism, but rather a dissecting aorta.
• Red rules: Memorial Hermann has three rules that require absolute compliance. The patient identification must be checked and verified before any treatment, medication administration, or moving the patient from one place to another. The health system makes a point of not including the room number in the identification verification process, to avoid the too easy assumption that you have the right patient if you’re in the right room. The other rules require a formal time out before procedures, even procedures performed in a patient room, and a two-provider check for high-risk medications and blood transfusions. The computer system requires that, for high-risk medications and transfusions, two licensed providers must individually sign into the system with their own passwords.
• Hand hygiene secret shoppers: Memorial Hermann has hospital personnel who discreetly watch for proper hand hygiene and record what they see. Failure to comply with hand hygiene is noted but only by the type of employee, such as a nurse or technician, not by name. Memorial Hermann reached 90% compliance in 2012 and is now at 95%.