Tuesday, August 27, 2013

“I Think They Forgot to Reset the Bed Alarm.”

Recently, a man and his daughter came to see me in my office. They were upset because their wife and mother had fallen and broken her hip while an inpatient at GBMC. She had come in for an elective surgical procedure and was a bit disoriented post-operatively. A unit staff member had helped the patient out of bed in the middle of the night and had then assisted her back into the bed. Sometime later, the patient tried to get out of bed again to visit the bathroom and fell, fracturing her hip. It seems that the staff member who helped the patient out of bed had forgotten to reset the bed alarm so that when the patient got up on her own, the alarm did not sound and the staff was not alerted to the impending danger. The staff had correctly identified this patient as high risk for falls and had the appropriate equipment for fall prevention in the room.

Reliability means what should happen, happens, and what should not happen, doesn't. In this case, a woman under our care fell and sustained a serious injury. This should not happen. But why did it happen and what should we do to make sure it doesn't happen again?

Our Falls Team has dramatically reduced the number of falls at GBMC. Preventing falls in the hospital, especially among the physically compromised, is very difficult. It requires vigilance among the staff, and standard work using evidence-based care to do this. One miss, as in this case, can cause serious injury. Until a few months ago, we had high defect rates in the use of all of the important safety devices (alarms, socks, wrist bands, and signage) on some days on some floors. Now, it is very unlikely that a high fall risk patient doesn't have all of the equipment in place. But even with the equipment in the room, most of our beds have alarms with a design flaw: to take a patient out of bed safely you first shut off the alarm, and when you put the patient back in the bed you have to remember to turn the alarm back on.

These bed alarms are examples of active safety devices. The problem with such devices is that they require an action on the part of a human to operate correctly. But humans are not perfect and they sometimes forget, especially when busy caring for many patients at once. If our nurses care for 80 patients a day with bed alarms, and the patient gets out of bed five or six times a day, that’s almost 500 times a day the staff must remember to reset a bed alarm. Our nurses and technicians work so hard it is easy to see how one of them could get distracted and forget to reset the alarm. But if we get it right 499 times out of 500, and the one time we miss results in a patient injury, we still have to find a way to get to perfection.

In the old days, our reaction here would have probably been to reeducate the staff on the importance of resetting the alarm. This action is silly at best. When our staff gets something right 99% or more of the time, is it that they don’t know that they should reset the alarm? Of course not, it’s that they forgot, so education is not likely to fix the problem.

High reliability organizations search for passive safety devices – ones that don’t require human action and therefore are much less likely to fail. As a pediatrician who has treated a number of drowning victims, I recall when gates in fences around pools used to require an adult to remember to pull the gate shut to keep young children from wandering into the pool area unattended. Now, most pool gates have a spring that pulls the gate back into the closed position and a self-catching lock…the gate shuts itself after someone enters. Our falls team recognized that even the smartest, hardest-working staff member will eventually forget to reset the bed alarm. GBMC is now beginning the replacement of our beds and purchasing new beds that have alarms that reset automatically. We now have a number of these beds already in place. In the interim, the Falls Team continues to test ways to “catch” that someone has forgotten to reset the alarm.

To err is certainly human; but as humans and as healthcare leaders, we have the ability to redesign our systems so that common human errors are blocked or mitigated before they cause harm. We must study every event and find new ways to make our GBMC HealthCare system safer every day.

Let me thank everyone in the GBMC family for helping us get to higher reliability and closer to our vision.

14 comments:

  1. Kudos to GBMC for correctly identifying the problem!!
    We need to identify all "active" devises and systems around the hospital and effectively replace them with "passive" ones.
    Example: A secretary working for the CIA accidentally pushed "reply all" on a confidential e-mail that exposed CIA operatives' identities to each other, which resulted in a major confidentiality breach. Who's responsible? The software engineering department who had such an e-mail option to exist in the first place.
    Aim high - at systems in place - to avoid opportunities for error.

    ReplyDelete
  2. I'm sorry this happened, but I think it's time we enlist family members to help us in our quest to prevent their loved ones from doing harm to themselves. Nurses and techs cannot be everywhere at once. And if the bed alarm HAD been turned on, who's to say someone would have gotten to the patient before she fell? Other countries welcome families at the bedside around the clock - we do our best to prevent it. Why is that?

    ReplyDelete
  3. Thank you Dr. Chessare in being transparent and continuously placing efforts on process improvement. We all strive for excellence but indeed we are all human-where human errors exist but we in a caring compassionate environment/business of healthcare want to minimize these errors to protect our patients.
    Nancy-co-chair Falls Team

    ReplyDelete
    Replies
    1. Thanks for all that you and your team have done to make our patients safer, Nancy.

      Delete
  4. It should be noted that GBMC has ZERO falls with injury for the month of July! Thank you to our staff who are working hard to make a difference. We all feel terrible when an injury occurs but we must remember to stop and celebrate when we have made some good progress! Carolyn Candiello, VP Quality and Patient Safety

    ReplyDelete
    Replies
    1. Thanks, Carolyn. Yes, we should celebrate the wonderful work of our people in reducing falls.

      Delete
  5. Thanks for the constructive analysis of the fall issue and for being part of the solution.Great job!

    ReplyDelete
  6. I agree with the above comment concerning family and visitors. We should encourage them to stay with the patient, especially in the face of a patient with the potential for confusion. Teachers do not hesitate to solicit the help of parents who are available to help. Why can't healthcare do the same?

    ReplyDelete
  7. Because the ratio of staff to patient on certain units are different, it would be a good idea for families and friends be invited to stay with patients. Most of the falls happen at nights when there are less staff to go around.

    ReplyDelete
    Replies
    1. Thanks to all those who have commented about accepting the help of the family to make patients safer. I agree that we should enlist family members in our quest. However, family members were at the patient's bedside at the time of our most recent fall with injury so this is not a failsafe, either.

      Delete
  8. Agreed, it's not a failsafe, but if family members were right there and the patient still fell, it clearly didn't matter that the bed alarm wasn't turned on. It sounds like they were upset with themselves; instead, the blame is placed on GBMC staff and the bed alarm. Not fair.

    ReplyDelete
  9. Unfortunately this happens a lot of times. I had a family member who fell and hit his head at GBMC overnight. I had offered to come in and stay with him, and was told by the nurse that "they would be okay." I trusted this, because she told me this. The next morning when I called to check in I was told that he had fallen. Three days later he suffered a bleed in his brain, and passed away while still in the hospital. While I can talk about this now (just being over a year ago), my anger is still there, and I don't think it will ever go away completely. I know mistakes happen, but if you don't implement precautions put in place to minimize the number of occurrences, then THAT is negligence. I am sorry that this happens to other families in addition to my own. They should be grateful that their family member is still here.

    ReplyDelete
    Replies
    1. Thanks, Anonymous. I don't know of the case you are referring to but I am very sorry. I can assure you our falls rates are much lower than they were and the very point of the blog is to stay focused until we get to zero falls.

      Delete

Thank you for taking time to read "A Healthy Dialogue" and for commenting on the blog. Comments are an important part of the public dialogue and help facilitate conversation. All comments are reviewed before posting to ensure posts are not off-topic, do not violate patient confidentiality, and are civil. Differing opinions are welcome as long as the tone is respectful.