What do you do after multiple adverse events?

Seattle Children's goes on record after deaths

After one patient death in 2009, an error with an adult patient this year, followed by two patient deaths, Seattle Children's Hospital has been in a lot of discussions with not only the state's department of health and The Joint Commission, but the media and its staff as well.

Cara Bailey, BA, MBA, vice president of continuous performance improvement at Seattle Children's, says she almost felt as if she were in a reality television series as the stories kept breaking in the media in late September. In her role, Bailey is responsible for the hospital's continuous performance improvement resources. She says the organization adopted and has been using the Toyota production system/Lean methodology for 10 years. She also is responsible for patient safety, clinical quality improvement, and regulatory compliance.

"Through this crisis, my role has really been to, first of all, mobilize the right resources to both do the immediate root-cause analyses and really get in there and understand what happened and what to do and what the root causes are. But it has also been to say, 'OK, what are the things the staff are telling us that we need to go out and take a closer look at using our continuous performance improvement methodology?'" she says. In terms of mobilizing resources and people, she is working to make sure the core leadership group is managing the issues. One of those people, she says, is the organization's vice president of marketing communications. "So we're, as a group, constantly in contact with each other regarding the media and just both the internal and external communication strategy because all of this work is obviously linked," she says.

On the regulatory side, her job has been to ensure the hospital is talking to all "the right people" within all regulatory bodies — The Joint Commission, the Centers for Medicare & Medicaid Services, and the state's health department.

"One thing that I have learned, you have to be able to segment out the work and have people going out and doing it. There is just so much that comes at you all at once. The first decision we made with the first medication error was that we were going to be transparent about it. It was in keeping with our philosophy, and we did send a letter to all of our employees and our medical staff," that ultimately made its way to the media, she says.

"It's really hard to imagine that you can send an e-mail or a letter to 5,000 of your employees and associates and expect that it's not going to make it's way to the media when it is dramatic," she says. Many peer hospitals, she says, have "kind of looked at us askance, [asking], 'Why are you talking about it?' Kind of like, 'You have made your own misery here because you have been out there talking about it.'" But, she adds, the hospital's policy has always been to disclose to patients, families, and staff any adverse events that happen.

However, much of the media's coverage has been confusing regarding when and why the four events occurred, she says. They also reported the hospital was suspending operations for a day to review their policies. That was really a bit of a "misnomer. We realized that we were going to need to really make sure that we were reinforcing some basic safety behaviors and so we started that right away," Bailey says.

The hospital called it a "rolling stand down," after the military's reaction to an event such as a plane crash when they "stand down" all operations for a day to review safety principles and to ensure everyone's understanding of those basic elements.

The hospital held a series of forums in which employees discussed behaviors — specifically around verbal orders, Bailey says, which was identified as a particularly risky area. The purpose? To create a standard that everyone follows. "So within about a week to 10 days, we had seen about 2,500 to 2,600 of our employees in those forums and then followed up with the ones that weren't able to be there." That was followed up with a forum on a Saturday.

At about the same time, leaders were sent into the workplace to review things they had learned from speaking intensively with staff during the forums about what employees saw as barriers, problems, or obstacles. In speaking with them, for example, about verbal orders, "they told us all sorts of things. We heard a lot about our clinical information systems and how easy they are to access or not. We heard things about interruptions in the workplace and distractions and interruptions of all kinds. We heard some specific things about equipment. A lot of themes began to emerge, and given that input, we started to work on what we could do on this patient safety day that starts to get at some of what we have heard," Bailey says.

Thirteen projects emerged from discussions with staff. One group worked on order sets for verbal orders as part of the clinical information system. "We believe that by having these order sets, it not only makes the care more consistent, it also makes it easier for the prescribers, as they are going into the information system to order the right thing. So a lot of it comes down to human factors and what's going on in the environment," Bailey says.

Another group worked on interruptions in the operating room. One used simulation to identify what the standard work involved with verbal orders should be, and another also used simulation to evaluate how staff should escalate problems. "We had one group that was working on the standard process for medication administration. We had two groups that were working on automated dispensing cabinets on the unit and looking at what's in those cabinets and how should we make that more consistent. So we had a wide variety of groups all working on specific projects around medication safety. People were so energized by it," Bailey says.

She says the work is not "rocket science," but about how to simplify a very complex environment. One thing that was brought up in discussing interruptions was the wireless phones nurses carry with them. "[T]hose things go off all the time. A nurse shouldn't be thinking about her phone when she is in a medication room preparing medications," Bailey says. Staff also discussed what the protocol should be if you couldn't locate a staff member on his or her phone.

"I think the other thing that we have discovered around that is because this technology can tend to make the environment really seem urgent all the time, and so even separating out what's truly urgent and needs to be addressed immediately versus what can wait or what things should we be anticipating so that they don't become urgent or emergent," she says.

All four cases had something to do with medication overdoses or errors in medication administration, she says. In one of the events, an infant was given an overdose of calcium chloride. Immediately following the incident, calcium chloride was removed from the automatic dispensing cabinets in all the units, she says. Other medications were also removed to make it harder to make an error.

Bailey says it's not just about root causes but the themes that emerge to make it easier to make errors.

Bailey says all the events were reported to The Joint Commission, and as of press time, the hospital had submitted its root-cause analyses and was waiting for The Joint Commission to schedule a conference call to discuss the findings. Of the four events, The Joint Commission determined three did not meet its definition of sentinel events. The calcium chloride event did, she says.

"Any time these things catch media attention, then whether or not they meet a list of never events, it's going to bring your regulators out," she says. The state came in and has reviewed all four cases. The facility licensing review is, as of press time, complete on three of those. She says the state health department did release a statement saying "that those investigations were complete and they found no deficiencies in the hospital systems and processes on those three cases. Now, at the same time, there are also investigations going on into some of the individual people involved from the nursing committee and the medical quality assurance committee. [They] are being looked at separately for individual licensing; those investigations generally take longer," Bailey says.

"I think it's all about, ultimately, how did we really cut down the complexity of our environment? And it plays out in things that are as concrete as interruptions. It also plays out in recognizing that when patients are so complex, how we do make our system such that the staff are supported to take care of each patient one at a time and that the information systems and the other things around them make it easy for them to do the right thing — not make it more complicated to do the right thing. That's the ultimate systems challenge, I think."