Category: BOARD POLICY ADMINISTRATIVE PARAMETERS Title: Stop the Line : Authority to Intervene to Ensure Patient Safety Approved by: PHSA Board of Directors Reference Number: AS 130 Last Approved: June 17, 2015 Last Reviewed: June 28, 2016 1.0 PURPOSE 1.1 To assist Provincial Health Services Authority (PHSA) and its personnel in promptly detecting, appropriately intervening, and reporting potential patient safety events. Patient safety events are any event that may result in death or injury not related to the patient s natural course of illness or underlying condition. 2.0 TERMINOLOGY Refer to Appendix A for definitions of the terminology used throughout this policy. 3.0 POLICY 3.1 PHSA is committed to patient safety and to ensuring that all personnel understand their individual responsibility and authority to intervene to ensure patient safety by using Stop the Line to clearly express patient safety concerns, and when asked to do so by others, to stop and respond to an expressed patient safety concern. When patients and families raise safety concerns, PHSA staff should assist in addressing the concerns as appropriate. 3.2 This policy is supported by and should be read in conjunction with the PHSA Resolution of Respectful Workplace and Human Rights Issues Policy. 4.0 SCOPE The standards of behavior set forth in the policy are intended to apply to all PHSA personnel, employees, contractors, medical staff and students within all PHSA agencies/programmes, as well as employees of academic institutions with whom the PHSA is partner. Although Stop the Line policy focuses on preventing events that have the potential to seriously harm a patient, all personnel are expected to use Stop the Line to stop any practice that has the potential to be harmful, regardless of the degree and likelihood of physical, mental, emotional, or psychosocial injury.
5.0 PROCEDURE 5.1 GENERAL 5.1.1 All personnel have the explicit responsibility and authority to immediately intervene to protect the safety of a patient. This includes protecting the patient from potential harm and/or averting a patient safety event which may include failure to progress care that could result in harm. 5.1.2 Upon receiving a request to Stop the Line, personnel will immediately stop and respond to the expressed patient safety concern by: Asking what safety concern do you have? (i) (ii) (iii) reassessing the patient s safety and initiating appropriate actions to reduce patient harm. collaborating / consulting with team members to decide on the best plan of action. clearly communicating the plan of action to minimize patient risk and harm. 5.1.3 Following an explanation and plan of action personnel will ask are we okay to proceed? This process will repeat until the patient safety concern has been addressed which may require escalation to appropriate supervisors or department heads. 5.2 TYPES OF SITUATIONS 5.2.1 Emergency Situations When emergency intervention is warranted, assistance by the most expedient means available should be sought, which might include depending on the circumstances: (i) requesting immediate consultation (ii) transferring to a critical care area (iii) initiate escalation of care guidelines if available (iv) calling a Code Blue (v) calling 911 Such necessary emergency interventions may be initiated without a physician s order. However, orders for care are to be documented once the patient s imminent risk is contained. Situations warranting immediate intervention may include any event that may result in death or injury not related to the patient s natural course of illness or underlying condition. 2
Examples may include: (i) (ii) (iii) (iv) (v) Potential for overdose of medication Assault Care giver under the influence Willfull intent to harm Poor decision-making due to care provider indifference (i.e. attempts to ambulate a patient following a fall or with a likely fracture) 5.2.2 Non Emergency Situations In non emergency situations personnel fully pause, care and discuss concerns 5.3 METHODS OF INTERVENTION 5.3.1 The method of intervention should be prioritized in an attempt to maximize timeliness and effectiveness in restoring patient safety while minimizing intrusion into the provision of essential care, minimizing psychological trauma of the patient and/or the family and any further physical harm to the patient. 5.3.2 Methods of intervention include: Direct Communication The reporter verbally communicates the identified safety issue directly to personnel providing care using Stop the Line. The reporter uses a consensually agreed upon code word or phrase that indicates a patient safety risk has been identified. Once the code word or phrase has been stated, the personnel must immediately stop and respond. Charge Nurse/Supervisor Notification If the response to direct communication with the care team member(s) is not adequate to restore patient safety, the reporter contacts the charge nurse immediately. Communication Using the Chain of Command If the response from the unit manager/supervisor is not adequate to restore patient safety, the reporter immediately follows agency chain of command process. 3
6.0 ACCOUNTABILITY 6.1 PHSA PERSONNEL 6.1.1 All personnel are responsible for conducting themselves within the spirit of this policy and for appropriately using the Stop the Line to enhance patient safety. 6.2 ANY PERSON 6.2.1 Any person who observes or becomes aware of any situation that may cause imminent patient harm has the authority and responsibility to speak up and request the process be stopped in order to clarify the patient safety situation. Concerns may be raised by patients and families, and this should be addressed in a similar manner as appropriate. 7.0 REFERENCES AND RESOURCES BC Patient Safety & Learning System for the Provincial Health Services Authority (2009). Canadian Medical Protective Association (2015). Disclosing harm from healthcare delivery: Open and honest communication with patients. Canadian Patient Safety Institute (2011). Canadian Disclosure Guidelines: Being Open with Patients and Families Furman C, Caplan R. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007; 33(7):376-86. Harvard Hospitals. (2006). When things go wrong: Responding to adverse events. Massachusetts. Author. Morath, Julianne M, RN, MS; Turnbull, Joanne E, PhD.: Leape, Lucian L. To Do No Harm: Ensuring Patient Safety in Health Care Organizations. 2004. Provincial Health Services Authority (2013), Commitment to a Culture of Safety, Policy AS100 Provincial Health Services Authority Critical Patient Safety Event Review Toolkit, 2013 PHSA: http://pod/hcq/critical%20patient%20safety%20event%20toolkit/cpser%20toolkit% 202014.pdf BCEHS: https://intranet.bcas.ca/areas/qsrma/pdf/cpse-phsa-toolkit.pdf Seeking Perfection in Healthcare: Applying the Toyota Production. www.massmac.org/newsline/0206/vs1_05.pdf 4
World Health Organization (2009). International Classification for Patient Safety Framework (Final Technical Report) http://www.who.int/patientsafety/implementation/taxonomy/icps_technical_report_en.pdf 8.0 APPENDICES Appendix A: Definitions 5
APPENDIX A: DEFINITIONS All PHSA patient-safety related policies can include one or more of the following definitions: Critical Patient Safety Event means an event requiring a mandatory review and response as defined by: A confirmed severe or catastrophic harm with a direct causal relationship between care or service provided (or that should have been provided) and the harm; or Any confirmed Never Event based on an agency-defined list. Culture of Safety means an underlying philosophy of the workplace in which a shared and constant commitment to safety permeates the entire organization and is characterized by: an acknowledgement of the high risk, error prone nature of the organization s activities; a non-punitive environment where individuals are able to report patient safety events or near misses in order to optimize patient outcomes; the expectation of collaboration across disciplines and sectors to seek solutions to vulnerabilities; and organizational willingness to direct resources to address safety concerns. Disclosure means the process by which a patient safety event is communicated to the patient by healthcare providers. Event means something that happens to or involves a patient Harm means impairment of structure or function of the body and/or any deleterious effect arising there from. Hazard means a circumstance, agent or action with the potential to cause harm. Patient Outcome means the impact upon a patient which is wholly or partially attributable to an event. Patient Safety means the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. Patient Safety Event means an event or circumstance which could have resulted or did result, in unnecessary harm to a patient. Harmful Event means a patient safety event that resulted in harm to the patient. Never Events is a list of patient safety events that all PHSA Agencies have created and are deemed to be must never happen events. If an event on the list occurs, it must automatically be reviewed as a Critical Patient Safety Event. No Harm Event means a patient safety event which reached a patient but no discernible harm resulted. Near miss means a patient safety event that did not reach the patient. 6
Preventable means accepted by the community as avoidable in the particular set of circumstances. Policy Created on: June 22, 2006 Revision Dates: May, 2011 June 26, 2014 May 20, 2012 June 17, 2015 June 26, 2013 June 28, 2016 7