Lessons from Chicago

Transcription

1 Lessons from Chicago Lela Holden, PhD, RN Patient Safety Officer Edward P. Lawrence Center for Quality & Safety Massachusetts General Hospital October 5, 2010

2 Let s hear from Catherine Zeta-Jones 2002 Movie Chicago, best picture She & Renee Zellweger are in jail in Chicago s Both accused of murder Both are performers Richard Gere has not yet rescued 2

3 Long History of Innovation MASSACHUSETTS GENERAL HOSPITAL Charter to open --about to enter our 3 rd century Home of anesthesia first used ether Pioneered drug libraries in infusion pumps On US News List of Best Hospitals--#5 3

4 I Can t Do It Alone Everyone Has a Role To Play Clinicians Clinical Engineers Vendors Journalists Regulators 4

5 I Can t Do It Alone Not long ago 89-year-old man was found unresponsive Not breathing in his bed Despite heart monitoring and oxygen saturation monitoring 5

6 I Can t Do It Alone Not long ago Investigation revealed that the bedside monitor alarm audio volume had been turned off Central monitoring (hallway) lethal arrhythmia alarm default setting was off 6

7 I Can t Do It Alone Bedside monitor alarm audio volume had been turned off ---no one knew when or why Competing goal: quiet environment Lethal arrhythmia alarm default setting was off Very few knew this was possible 7

8 I Can t Do It Alone Further investigation determined that: A lower level 2-beep audio alarm on the central monitor had been signaling that the patient s oxygen and heart rate were low Staff had not detected alarm 8

9 I Can t Do It Alone Further investigation and discussion: Confusion----regarding system settings 2 central systems 7 models & multiple software versions Large number of patients on monitors Lack of standards for monitoring Alarm fatigue/desensitization related to devices 9

10 Teamwork Grows in Adversity Event was reported to the MA Department of Public Health About this time---and totally coincidentally the CMS (Centers for Medicare & Medicaid Services) arrived for an unannounced survey 10

11 And the regulators CMS staff Part of follow-up of a certain percentage of facilities that have completed a review by the Joint Commission They stayed 2 weeks and went throughout the hospital, and asked for safety events 11

12 And the press. Two articles in the Boston Globe. Feb. 21, 2010 April 3,

13 Dr. Lucian Leape, a specialist on medical safety at the Harvard School of Public Health, said one key question for manufacturers is why they would ever make a machine that allows hospital staff to turn off a critical alarm. Every piece of equipment we have has a failure rate, things go wrong, he said. But how come there are devices where this is possible? Why do you have a monitor you can turn off? Feb 21,

14 Alarm fatigue linked to patient death: US agency says monitors at MGH unheeded Boston Globe article April 3, 2010 Federal investigators concluded that alarm fatigue experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January. 10 nurses on duty that morning could not recall hearing the beeps at the central nurses station or seeing scrolling tickertape messages on three hallway signs 14

15 Patient safety officials said the tragedy at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because alarms malfunctioned or were turned off, ignored, or unheard. This is one of the most frequent and serious problems we see, said Jim Keller, a vice president for ECRI Institute, alarms for patient monitoring are listed as #2 on the top 10 list of health technology hazards. 15

16 Lessons to advance teamwork Biomedical Engineering: No double check when monitors were rolled out---the company (GE) and clinical staff Now comprehensive process to review all defaults Now have standard defaults 16

17 Lessons to advance teamwork Biomedical Engineering: Greater trust with clinicians---these independent validations of the equipment are now seen as just that----not interpreted as insulting what, you don t trust us? No MORE 17

18 Another wise woman These are very complicated issues.... So are questions/problems related to $$$$ Suze Orman she has guiding principles: People First Then Money Then Things 18

19 Principles to guide healthcare decisions Patient Safety First Then, The Team of the Many: clinicians, engineers, vendors, regulators collaborate in positive manner together Then, The Team of the Few we all must engage... we must all speak up 19

20 With Positive, Unified Teamwork Comes a powerful, new production... As we see again from Chicago 20

21 New & Better Production My hat is off to all of you, for all you do Here s to great collaboration today and in the future 21