Proactive approach makes errors plummet

Safety errors move to forefront

Identifying ways to improve patient safety has become a high priority at New Mexico Veterans Affairs (VA) Health Care System in Albuquerque, and communication between patients and health care workers and staff and management is the key to its success, says Melanie Douglas, RN, patient safety manager.

Safety issues are brought to the forefront through incident reporting, which is a written report about an error or close call, or staff can call on a reporting line and give a narrative of the incident. The narrative reports can be given anonymously if the caller doesn’t wish to leave his or her name.

Proactively, the medical center receives safety alerts from several organizations including the Joint Commission. Staff in the safety department also stay alert to incidents reported by the media, such as the death of a 6-year-old boy in an MRI when an oxygen tank crushed his head. (Learn more about how to identify safety issues and prevent errors in "To improve safety, ask your patients," in this issue.)

"Whatever comes our way, we gather the appropriate group together and find out what we are doing to prevent this error and how we are ensuring that it won’t be a problem for us," explains Sharon Hartzell, RN, the utilization review and patient safety coordinator. For example, shortly after the newspaper report of the boy’s death, members of the MRI team at the VA medical center in Albuquerque and the supervisor met to discuss the steps they had in place to prevent a similar occurrence and review their safety practices.

When a safety issue is identified, a matrix is used to score the problem to determine if a root-cause analysis (RCA) is needed. If an RCA is needed, an interdisciplinary team best suited to examine that particular incident is assembled. "It is a systems approach looking at how we can prevent this from happening, rather than trying to single out a particular individual to blame," says Douglas.

Thorough review implemented

To come up with a set of actions that need to be taken, the team interviews staff and patients, reviews documentation, and often visits the scene where an accident or medical error occurred. The steps to improve safety are presented to senior management who review them and either sign off on each one or provide additional feedback.

If revisions are recommended, they are made by the team. Once the set of actions receive final approval, they are given to the appropriate personnel with a timeline for completion. The safety coordinator follows up to ensure the steps were implemented.

For example, when the wrong medication was administered to a patient in the emergency department, it was determined that similar IV mixtures were kept in too-close proximity, side-by-side on the same shelf. Therefore, steps to improve safety included changing the labels on the IV mixtures and storing them in separate places. When a safety alert covered the dangers of leaving concentrated potassium chloride on units, it was removed before it was administered by mistake. The vial was similar to other medication containers, says Douglas.

"We are all human and we make mistakes, so it is important to try to eliminate safety hazards, such as storing IV mixtures side-by-side on a shelf, to eliminate the potential for error," she says.

To help staff become more comfortable with the process, they are given information on reporting incidents and potential mistakes during staff meetings and also in the quality improvement newsletter. They also attended a hospital wide inservice about the new nonpunitive systematic analysis approach the VA has taken. However, many fear a reprisal and are still hesitant to report close calls. This attitude is slowly changing as more and more staff members are assigned to RCA teams to conduct an analysis and see how the teams can come up with good recommendations for changes.

Educating patients about the role they play in eliminating the potential for mistakes is also important. A patient pamphlet is being implemented that teaches patients how they can help prevent medication errors by knowing which medications they are to receive and identifying them before the nurse administers them, says Hartzell. The pamphlet also advises patients of potential medication and dietary supplement interactions that could be harmful and the importance of reporting the supplements they are taking, such as vitamins and herbs, to their physician.

"It is important to create a culture of safety so staff will call and say, This wasn’t an accident, but it sure could have been. How can we work to fix it?’" says Douglas.


For more information about creating a culture of safety and teaching staff and patients to participate, contact:

  • Melanie Douglas, RN, Patient Safety Manager, New Mexico VA Health Care System, 1501 San Pedro Drive S.E., Albuquerque, NM 87108. Telephone: (505) 265-1711, extension 4785. E-mail: