Proven, error-reducing approaches—Try them in your ED

"There are several specific techniques taught by MedTeams that cause errors to [be] diminished," notes Matthew Rice, MD, FACEP, medical corps chief at the department of emergency medicine at Madigan Army Medical Center in Tacoma, WA. Here are several MedTeams concepts that have been proven to reduce errors:

• Checkbacks. The "checkbacks" system is used by pilots and flight crews to ensure effective communication and minimize errors, explains Dallas Peak, MD, FACEP, clinical assistant professor of emergency medicine at Methodist Hospital in Indianapolis and a physician investigator for MedTeams. "In MedTeams training, we stress that all verbal orders are to be acknowledged verbatim. This will minimize the possibility for errors," he says. "The order-giver has a chance to hear what was said and correct a misstatement, while the order-receiver ensures the accuracy of what he or she heard."

Repeating medication orders is normally only done by nurses, says Gregory Jay, MD, PhD, FACEP, director of emergency medicine residency research at Rhode Island Hospital in Providence. "Physicians should be checking with someone as well," he stresses. "We teach that when a med is drawn up, the person drawing it up needs to check back’ that the dose is correct. If the person who ordered the dose isn’t there, you need to check it back’ with someone else, another physician or nurse. The goal is to eliminate medication errors."

At Madigan’s ED, the nurse is required to repeat the order out loud so it’s clear what the physician actually wanted, notes Rice. "We have had several cases where bad or less than ideal outcomes or medication errors were avoided because of the checkbacks,’" he reports.

Techs have alerted nurses or physicians to certain situations that in the past they may have ignored because they weren’t included, Rice says. "The techs have notified people about circumstances that were changing," he explains.

Physicians believed that one patient with chest pain had no cardiac involvement, recalls Rice. "The tech left with the patient was made aware of our concerns, but quickly picked up on the patient’s subtle complaints of back pain," he explains. "The tech brought this to the nurse’s attention and brought the physician to the bedside. At that point, the patient became bradycardic. If the tech had waited until the patient started to turn bad, there could have been less than an ideal outcome."

• The two-challenge rule. "This is one of the most effective empowerment tools I’ve ever seen," says Peak. "Whenever a team member questions a decision, that team member has a responsibility to seek resolution. In fact, they may seek two challenges,’ first with the person who is directing them, and then take it to a superior."

The two-challenge rule encourages a permissive atmosphere, notes Rice. "If even the newest, least empowered people see something wrong, they have permission and an actual responsibility to challenge that in a professional way," he says. "At that point, they will either correct a potential error or be educated as to why they were mistaken, so they are a better provider."

In army aviation, if a helicopter pilot is flying directly into a mountain, the pilot who is not on the controls is taught to verbally challenge the action, explains Peak. "The pilot on the controls is supposed to respond. If he doesn’t give a response or gives a nonsensical response, the other pilot is supposed to challenge him again. If he gets no answer or an irrational answer, that pilot is then authorized to take over the controls," he says.

The same concept applies to the ED. "The whole point is to move the welfare of the mission or the patient, onto the whole team," says Robert Simon, EdD, chief scientist for the crew performance group at Dynamics Research Corporation in Andover, MA.

The key to this concept is that the responsibility lies with the person who perceives the problem, says Peak. "They are empowered to supersede rank or traditional hierarchy in order to resolve the issue," he explains.

However, MedTeams stresses the value of professional respect. "The two-challenge rule may seem disrespectful to some physicians," says Peak. "But human fallibility is a fact of life. If another medical professional has a concern, that concern should be addressed, regardless of their relative level of professional training."

A nurse may challenge a plan to send a stroke patient to CT scan when the patient was deteriorating and required intubation, Simon explains. "That doesn’t mean the doctor has to agree. The physician may say, The patient may appear to be deteriorating, but I know she is stable, so let’s move on.’ We are not trying to take authority away from people. We are trying to help them make better decisions."

The two-challenge rule was formally implemented into the ED’s policy and procedures. "The fact that we’re a teaching facility and our providers are open to new ideas has allowed us to easily integrate this into our daily practice," says Peak.

At Madigan, an ED physician ordered Reglan, an antiemetic, when he actually wanted to give the patient Namidadine for ulcers. A nurse caught the error, and challenged the order. "In that case, there may not have been a bad outcome, but the patient would have gotten the wrong medicine," notes Rice.

Challenging physicians may initially ruffle some feathers, notes Simon. "We are not a school for mutiny, and know physicians are responsible for the clinical progress of patients through the ED. We’re not trying to subordinate that, but at the same time, everybody is responsible for the patient," he says.

Cross monitoring. This is a powerful mechanism to reduce the error rate, advises Simon. "A nurse in a busy ED asked a physician, can a patient with NSAID allergy take Alleve? The attending physician answered yes, but another nurse asserted that Alleve is NSAID. By doing that, a potential injurious dose was avoided," he says.

As many as half the serious adverse events in EDs could have been caught by someone who was in the area, stresses Simon.

The concept is to take responsibility for the patient, Simon explains. "If you hear that a patient has been administered an IV that you think is contraindicated, then you have to speak up. You can’t just go on to your next task," he says.

Advocacy and assertion. If a resident physician routinely orders IVs for intermediate patients, a nurse may question the practice, Simon explains. "The nurse may state that it increases the patient’s length of stay, increases the cost, makes patients uncomfortable, and possibly also causes complications," he says. "After a discussion, the physician modifies his practice of routinely ordering IVs."

However, the key is to teach people ways to present these things to one another in nonthreatening, nonpersonal ways, Simon stresses. "The nurse would approach the physician and say, I notice you are ordering IVs for all patients in this area. I think when we do that, it increases our workload as nurses quite a bit," he explains.

Avoiding accusatory tones is key, says Simon. "If a nurse talks to a physician in terms of what behavior do we want to change, and why, then they can discuss it from there," he explains. "The idea is not to berate or correct another provider in front of a patient. If that occurs, the provider needs to explain, When you reprimand me in front of patients, I lose credibility, and we are not performing effectively as a team.’"

Editor’s Note: For more information about MedTeams, contact Robert Simon, EdD, CPE, Chief Scientist, Crew Performance Group, Dynamics Research Corporation 60 Frontage Rd., Andover, MA 01810. Telephone: (978) 475-9090 ext. 1316. Fax: (978) 474-9059. Internet: