HOSPITAL ROUNDS

Can we live a "Just Culture?"

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On July 5, 2006 obstetrical nurse Julie Thao gave Jasmine Gant, a 16-year-old scheduled for induction of labor, IV bupivacaine (Marcaine), an anesthetic intended for epidural administration instead of the IV penicillin that had been prescribed to treat a streptococcal infection. The patient suffered a cardiac arrest and couldn't be resuscitated. An infant son was delivered by cesarean section.

This is a clear case of an adverse event that in health care is classified as a sentinel event, a medical error leading to death of a patient. Who is to blame? Who is responsible?

For 16 years Julie Thao had been a good obstetrics nurse, one highly regarded by her peers at St. Mary's Hospital in Madison, Wisconsin. Over the July 4 holiday she volunteered to work an extra shift, after working an eight-hour day shift. She was scheduled for a 7 am shift on July 5; she slept at the hospital at the end of the two shifts. The error occurred during the second half of that July 5 shift.


Nurse Thao allegedly failed to follow the “five rights” of medication administration (right patient, right medication, right dose, right time, and right route). She failed to use the patient's ID wristband bar-coding system installed on the unit three weeks earlier. The medications looked alike and were brought to the patient room before orders were given. She was obviously fatigued from working 20 of the prior 28 hours. Was she distracted, rushed?
Health care providers generally come to work to do a good job not to harm patients. They are, for the most part, dedicated individuals who see their work as a calling to improve the lot of mankind. What do we do when they make a horrible mistake?

St. Mary’s Hospital fired Julie Thao. The Wisconsin state board of nursing suspended her license and the state brought criminal charges. St. Mary’s Hospital settled a $1.9 million malpractice suit with the patient’s family. Nurse Thao was despondent. "I felt my soul banging on the inside of my chest to be set free," she said. "It could not bear to be inside this body, this person who had done this."

Several years ago David Marx, an engineer developed what is called Just Culture. Given the premise that most adverse events are a result of a system failure, errors are rarely caused solely by the actions of an individual. Individual responsibility for an error arises from intentional or reckless behavior or actions performed under the influence of drugs or alcohol.
Just culture may be difficult to implement. A young, healthy patient is dead. An orphaned infant, a grieving family and an outraged press and community exert tremendous pressure. How does the hospital respond? They fire the nurse.

An organization that adopts a Just Culture as one of its cornerstone principles should have a different response. First, the reason to use a Just Culture is have an organization where patient safety issues and concerns can be brought up in an open and safe atmosphere. An organization that uses individual blame will find that there is a scarcity of voluntary reporting, no learning and a poor safety record. Second, the initialization of a Just Culture starts with the board of directors and senior leadership. A standardized approach that investigates all incidents using an algorithm is needed.
The UK National Health Service has an on-line program that allows for a step by step evaluation of an adverse event.

The first point on the decision tree is whether the action was intended. If so, were the consequences intended? If not, did substance abuse play a role? If not, were safe practices violated? If so, then were the procedures available, workable, intelligible, correct and routinely used? Would another individual act the same way in a similar circumstance? The answers to these questions guide the evaluation of expectations, systems, and training with the determination of a system failing or an individual behavior problem.

If St. Mary’s Hospital had a strong Just Culture would this event be handled in a different way or could it have been prevented? There are a number of areas to consider. First, Nurse Thao was working extra shifts at a rate the data shows promotes unsafe acts. There should have been a strong policy that prevents nurses from taking on unsafe extra hours of work. The medications looked alike and arrived without a proper order. The newly implemented wrist band bedside medication verification was not working properly and nurses routinely circumvented its use.

An institution with a Just Culture would have quickly followed a standard algorithm and determined that, neither the act nor the consequences were intentional. That substance abuse did not play a role. That despite the fact that clear policies were violated, the training and systems were faulty and that others would have made a similar mistake. Julie Thao’s error might have been a natural result of the institution’s failure to protect the patient with the proper policies and systems. The institutions must accept the blame, work to correct their policies and have a process that aids the involved staff through the period of intense personal guilt and remorse that inevitably follows.

We need to separate the act from the outcome. What if Jasmine Gant had a brief arrhythmia and mother and baby were fine? Would the response be the same? Nurse Thao’s actions would be identical in both circumstances. Would the investigation of the event proceed in a similar manner with the purpose of preventing future similar events?

Could this happen at GBMC? Do we have the systems and processes in place to prevent such an error?

I spoke with Jody Porter, our senior vice-president for patient care services and Sue Bowen, our administrative director of L&D. We reviewed our policies and procedures with regard to epidural medications. Since this episode in Wisconsin, epidural catheter manufacturers have made their catheters a bright yellow. Unfortunately the ends where the medication lines are attached are the same for IV catheters and epidural catheters. Our medications for epidurals are premixed by the pharmacy. The drugs (fentanyl and bupicacaine) are highlighted in yellow and there is a hot pink label (like St. Mary’s) on the bag stating EPIDURAL use. Yellow stickers are placed on the epidural tubing stating “epidural use only”. I visited our labor and delivery suite and spoke to our nurses and one of the anesthesiologists. They showed me how they used the Omnicell for the medication and the special tubing. At our hospital it is the anesthesiologist who actually attaches the medication line to the patient. The antibiotics that are used in L&D are physically much different from the epidural medications as shown. The epidural mixture is on the left with the two antibiotics frequently used to the right. Ampicillin’s vial is attached to the bottom of the infusion saline and Cefazolin is in a foil container.

Nationally, a recommendation by the Institute of Medicine in 2004 to limit nurses' working hours has not been adopted. The institute, a nonprofit organization that advises Congress on health-care policy, said states should prohibit nurses from working more than 12 hours in a 24-hour period or more than 60 hours per week. "No real action has occurred," said Ann Rogers, a nursing professor at the University of Pennsylvania. Her studies have revealed an increase in fatigue and errors among nurses who work more than 12 hours in a row. Our practice is that nurses can only work a maximum of 16 hours in a 24 hour period. The lessons that we can learn are that medicine has the capacity to heal and cure, but also has a capacity to cause great harm. As healtcare providers we must be vigilant in following Hippocrates' first dictum: "first do no harm".

Simeon B. (Sam) Alvaran, M.D.

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On February 27, 2010 the colleagues and friends of Dr. Sam Alvaran gathered to honor his career in Anesthesiology at GBMC. Sam has retired this year and continues his battle with cancer. The evening brought together the GBMC operating room family including the many physicians of Physician Anesthesia Associates (PAA), nurse anesthetists, anesthesia technicians, OR nurses and technicians, PACU nurses, GBMC physicians and surgeons whose lives and careers were intertwined with Sam Alvaran. Evident throughout the evening were Sam’s love for everyone of GBMC and their love in return.

LaSalle D. Leffall, Jr., MD Surgical Hero

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As Black History Month draws to a close I would like to introduce you to one of my surgical heroes, LaSalle D. Leffall, Jr., MD. As surgical resident at Walter Reed in the 1970’s I had weekly grand rounds with visiting professors. The format was the presentation of interesting surgical cases followed by a discussion by the professor. It was at time of great education and great stress for us as residents as the professor would ask questions of medical students and residents on a certain disease process or surgical procedure that had been presented. We had several visiting professors who were chairmen of surgical programs from Washington, D.C., and Baltimore. The most outstanding was Dr. LaSalle Leffall from Howard University.


Following the case presentation Dr. Leffall would walk up to the podium, grasp it in both hands and ask “where are the 3rd year doctors?” (referring to the 3rd year medical students on their surgery rotation) Next he asked where are the 4th year doctors, and so on through the residency ranks. He would then dissect through the case and give us the important lessons by asking questions all around the room. I remember once when I was the chief resident that one of Dr. Leffall's quesions made it all the way around the room up to me. Luckily I knew the right answer and didn't disappoint Dr. Leffall.


One of his favorite sayings was “There are only two reasons that patients come to the doctor, pain and bleeding. Pain because it hurts them and bleeding because it scares them.” He would admonish us that “there are two diagnoses that you will never make.” Then he’d stop and look out over the conference room and restate “never make”. Then he would tell us in his precise diction, “The two diagnoses you will never make are the disease that you don’t know about, and the disease you don’t think about.”

Dr. Leffall also taught us how to say Johns Hopkins. He would say “the founder’s first name was Johns, not John. You wouldn’t say Pitt-burgh, it’s Pittsburgh”.


LaSalle Leffall was born in Tallahassee, Florida, on May 22, 1930, to LaSalle D. Leffall, Sr., who hailed from east Texas, and Martha Jordan Leffall, from northern Alabama. He grew up in the small town of Quincy, Florida. Both his parents were educators in the public school system of Florida. Dr. Leffall graduated as the valedictorian of his high school class, graduated summa cum laude from Florida A&M University, and was first in his class at Howard Medical School. He did his residency at Freedmen’s Hospital, now known as Howard University Hospital and completed a fellowship in surgical oncology at Memorial Sloan-Kettering Cancer Center.

Dr. Leffall performed his military service as Chief of General Surgery in the U.S. Army Hospital in Munich, Germany in 1960 and 1961. He then joined the faculty of Howard University College of Medicine. He was selected to be Chairman of the Department of Surgery in 1970. In 1992 he was named the Charles R. Drew Professor, occupying the first endowed Chair in the history of Howard's Department of Surgery.

During the course of his illustrative career, Dr. Leffall was awarded honorary degrees from nine universities and was the president of nine medical organizations. He was the first African-American to be elected President of the Society of Surgical Oncology, President of the American Cancer Society, both in 1978 and President of the American College of Surgeons in 1995.

He used his national positions to emphasize the problems of cancer in minorities. He held the first conference on cancer among black Americans in February of 1979. "I have tried to point out the problems of lack of access to care and the increased death rate”. In 1980, President Carter appointed him to a six-year term as a member of the National Cancer Advisory Board.

As much as he dedicated himself to the broader aspects of prevention, nutrition, and education as head of the American Cancer Society, Dr. Leffall continued to remind others that "the one thing we must never forget is that the object of our attention and affection is the cancer patient."

In 1987 M.D. Anderson Hospital established The Biennial LaSalle D. Leffall, Jr. Award. This award recognizes Dr. Leffall’s contributions to cancer prevention, treatment, and education in minority and economically disadvantaged communities. In 1989, the citizens of Quincy, Florida named a street, a path, and the surgical wing in the Gadsden Memorial Hospital in his honor. The LaSalle D. Leffall, Jr. Surgical Society was formed in March 1995; the Leffall Chair in Surgery at Howard University was established in February 1996. Dr. Leffall and his family established the Martha J. and LaSalle D. Leffall, Sr. Endowed Scholarship Fund and Endowed Professorship in Science at Florida A & M University in 1997 in honor of his mother and father. His memoirs entitled “Grace Notes—A Cancer Surgeon’s Odyssey,” was published by the Howard University Press in 2004.


In addition to his professorship at Howard University, was the chairman of the Susan G. Komen Breast Cancer Foundation; the President’s Cancer Panel; the Board of Directors of the National Dialogue on Cancer. Dr. Leffall and his wife Ruth have one son, LaSalle, III an honors graduate of Harvard College and the Harvard Law and Business Schools. He is the Executive Vice President and Chief Operating Officer of the National Housing Partnership Foundation in Washington, D.C.. Dr. Leffall is an avid tennis player and supporter of jazz music. Because of his long-standing and close relationship with Julian “Cannonball” Adderley, Dr. Leffall represents an important link with one of the most imposing figures in modern jazz.

Meet LaSalle D. Leffall, Jr., MD, FACS in this video clip from the Washington Post.

http://www.washingtonpost.com/wp-dyn/content/video/2006/08/29/VI2006082900628.html

"Get the stupid stuff right"

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In thinking ways in which to provide the best care possible to our patients at GBMC, I came across one recently that looks promising.

If there was a new product on the market that could reduce the rate of major complications in patients undergoing surgical operations by 36% and mortality rates by 47% would it be worth the investment? With 30 OR’s and 32,000 surgical procedures per year and a NSQIP mortality rate of 0.68% and an HSMR rate of 0.65%, perhaps we don’t need this new product. With healthcare reform still somewhat in the works, this new product might not be cost effective. Besides we have other priorities, such as showing that our EMR meets all the meaningful use criteria set forth by the federal government, making sure we can provide access to the newly insured and keeping a strong bottom line. But, just what is this new product? Perhaps we should make this investment, but what will it cost?

It turns out, it costs almost nothing. It’s the World Health Organization’s Surgical Safety Checklist. Published just over a year ago in the New England Journal of Medicine why hasn’t the surgical world embraced a tool that has been shown in a world-wide study to reduce morbidity and mortality? The answer is probably, us, the surgeons. It’s just not our culture. After spending a recent Sunday afternoon reading Atul Gawande’s new book, The Checklist Manifesto, I was struck, not only by his usual engaging review of the origin and use of checklists in other industries, but by his personal journey from skeptic to advocate. From the B-17 flying fortress that was felt to be too complex to fly, to the construction of modern skyscrapers, to the operations of a restaurant’s kitchen, Gawande shows that complex tasks can be completed with ease when managed by the use of checklists. Checklists help us not to forget the important things. They need to be simple and embraced as important tools to perform complex activities, like landing a jetliner or performing surgery.

Super Storm II

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GBMC is in to its sixth day of Yellow Alert (essential staff remains on site) facing back to back super storms. No sooner had the snow from the Super Bowl weekend storm been cleared, forecasters called for a second severe snowstorm to drop 1-2 feet with blizzard potential. The medical center has been fully operational throughout with full surgical schedules Monday and Tuesday. In anticipation of the second storm beginning last night over 200 staff stayed at the hospital. Many came packed for three or four days. Putting staff up in empty patient rooms was not an option since the house was full. As the supply of cots ran low the Maryland Emergency Management System was put to use.

Dan Tesch, GBMC's Emergency Management Director, uses the hospital's Ham radio system to talk with other members of the Baltimore County Radio Amateur Civil Emergency Service (RACES) group during the beginning of the second snowstorm. In short order 100 extra cots came from the Baltimore County Emergency Management Task Force supply at Towson University. The cots were quickly delivered to designated sleeping areas for staff.

Mike Forthman, VP of Facilities unloads the cots as Dan Tesch readies the cots for use.





Jody Porter, RN - Senior Vice President Patient Care Services and Chief Nursing Officer, and Jill Wheeler, RN - Nursing Administration, plan staff accommodations in GBMC's Hospital Command Center.

Our Civiletti Conference Center has been converted into a staff dorm, filled with cots. Staff that are staying for several nights are instructed to store their linen for the next night as the night shift comes in to get some rest.

Throughout, the GBMC Command Center remains on high alert. At 5 a.m. this morning George Bayless, VP of Finance, took over for overnight incident commander, Eric Melchior. Steve Cohen coordinates volunteer drivers and prioritizes staff pick-ups. Four staff handle phone calls as Dan Tesch, Michelle Tauson and Donita Dietz of Emergency Management, advise the Incident
Commander.


The Command Center includes an information board with the roles of all important personnel outlined. The individuals fulfilling each role are place on the board with their contact and cell phone numbers. To the left of the board are pre-arranged binders that outline the duties of each position with an action plan set out for the first 96 hours of any emergency.

Incident Commander George Bayless surveys the storm from the Emergency Department entrance. Area weather reports are reporting blizzard like conditions with wind gusts between 40-60 mph. Six volunteer drivers are still out this morning and we will assess the conditions as they return. As conditions worsen we may have to stop transporting staff altogether. Physicians are rounding on our telemetry patients to see if any patients can move to med/surg beds to alleviate a back up in the ED.

Surgical cases from our three OR’s were consolidated in the general operating room. All of the first case patients were here and on time. Only four patients called to cancel. We will do 26 cases today and have 68 scheduled for tomorrow. Our pharmacy, laboratory and radiology departments have remained fully staffed. There is a great spirit of teamwork throughout the organization.


There will be plenty of lessons learned with these storms. Our Command Center keeps a running list of items to be discussed in an after-action session, so that we can be better prepared in the future.



Plow and the “Gator” in the front parking area. Same area twenty minutes later.

Super Bowl Weekend Super Storm

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The GBMC Command Center is a buzz with activity dealing with a huge snowstorm that dropped between 2-3 feet on our hilltop campus. Our emergency operations began Friday evening just as the first flakes of snow began. The medical center immediately went on Code Yellow with all staff remaining in place. As the snow accumulated during the night two trees went down temporarily blocking our main entrance. We had a full complement of patients with fairly full ICU’s and telemetry units.














Eric Melchior our EVP and CFO ably took command. Staffing, supplies, snow removal, transporting staff from home, finding places for staff to sleep, feeding the staff, coordinating with the county and state emergency teams were all items of priority. Jody Porter, Senior Vice-President for Patient Care Services and Chief Nursing Officer and her team spent the first 48 hours ensuring that patients and staff were well treated.

Two and a half feet of snow is difficult to remove, but when it’s on a confined hilly campus the problem is compounded. Where do you put all the snow? Mike Forthman, VP for Facilities and his crew were in action all through the night, plowing, salting, and clearing downed trees. By Sunday morning the campus was fully cleared. Special thanks to all of Mike’s staff; Bud Butler, who kept the roads clear, Steve Cohen who coordinated 4-wheel drive volunteers who transported over 130 staff, and Jim Duerr who kept the supplies coming into the center.

Throughout the storm, the medical center continued to operate. An ambulance taking Torina McQueen of Owings Mills who had gone into labor and her fiancé, Saeed Hill, got stuck on the way to GBMC. The couple eventually made it to the hospital and safely delivered their first child - a boy named Tyson.

So many individuals worked tirelessly throughout the weekend. , COO Keith Poisson and Finance VP George Bayless, helped Eric Melchior throughout the weekend. Sunday morning Mark Thomas, VP of Human Resources took over command with Tressa Springmann, VP and CIO as liaison officer. In the Command Center Dan Tesch, GBMC Safety Officer, along with Michelle Tauson and Donita Dietz of Emergency Management and Safety were the guiding forces.

GBMC’s heroes are all of our staff, especially Cate O’Connor-Devlin (proprietress of the O’Connor-Devlin Bed and Breakfast), Kim Bushnell, Kathy Tracey, Sue Bowen, Eileen Skaarer, Michelle Patchett, Kara Lundberg, Kathy Lowerer, Sandra Scherer, Keith Jackson and C.J. Marbley who brought in DVD’s to show in the back of the cafeteria for the off duty staff. Dietary staff led by Keith Sappington, Matt Miller and Jennifer Christman fed our patients and staff. Their staff has been working non-stop for three days. Heath Jenkins’ Environmental Services with Mary Moise, and Transport Director, Judie Kusiolek with Chris Broadway have kept the hospital clean and functioning. Duke Bowen and his Patient Access staff kept patient registration up and running. Other heroes include: Joan Powers Smith from ED, Valerie Tighe from PEDs, Gretchen Bell, Jen Norris, and Janis Radcliffe from MNH, Genia Friia from M/S, Mark Kern and Jerry Mlinac from Pharmacy. Marketing’s Michael Schwartzberg and Kim Davenport have been posting messages on gbmc.org along with Twitter and Facebook. The “Gator Cam” on GBMC’s Facebook is worth a look.

On Saturday evening it was decided to pay staff that were required to say an hourly stipend while they were off shift and sleeping. Throughout this ordeal our staff has stayed positive and exhibited great team cooperation. One of our staff wrote:

“I just wanted to give my gratitude to how you handled the code yellow this weekend. I was stuck here at the hospital during the storm. I know I personally appreciate the fact that our meals were taken care of and we had a comfortable place to sleep on our unit. And finally, the fact that we are getting compensated for staying longer than our scheduled hours is great. I don't know if it was a legal issue or not, but it was the right thing to do. Everyone that I have talked to seems happy and appreciated.”

We are very proud of our staff for their efforts. More snow expected in two days!

Lean at GBMC

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"The best time to plant a tree is twenty years ago. The second best time is now." This African proverb comes to mind as GBMC embarks on an organizational performance improvement plan. We have chosen the Toyota Production System – Lean. We are doing this at the second best time in our organization’s history, now.

Under the able guidance of Tressa Springmann, Vice-President & Chief Information Officer, GBMC has begun laying the foundation by first educating the executive staff and getting their commitment. We trained fourteen of our staff to become Performance Improvement (PI) Masters in order to facilitate the process. This week we took 150 of our managers and directors to a two-day off-site training program on Lean. We wanted to give them a working knowledge of Lean tools so that they can work with our front-line employees begin to identify improvement areas, to drive out waste and to be ready to support kaizen events when they occur.


The Toyota guiding principles, particularly fostering a culture that enhances and respects employees fit nicely with our greater behaviors of respect, excellence, accountability, teamwork, ethical behavior and results. Lean focuses on our employees; the ones closest to the work as those who can provide the best solutions for improvement. Our job is to give them the tools to make their work more meaningful and efficient. Studies of bedside nurses show that they spend less than half of their time in direct patient care. All too often they are caught up in spending time, clarifying orders, documenting items looking for things or just waiting. Our staff deserve a well-ordered workplace, that is clean and uncluttered, where everything that is needed easily accessible, to allow them to do the things that really matter to them and that is their passion for choosing to work in health care.

Chinese philosopher Lao-tsu said “the journey of a thousand miles starts with the first step. We have taken our first step.