Mistake Proofing in the PACU

Everyone knows it – GBMC has outstanding anesthesia care. We have great anesthesiologists and nurse anesthetists. Our OR staff is second to none and we have excellent, dedicated nurses in our Post Anesthesia Care Unit. I have now been at GBMC for almost four years and I can’t remember a complaint about this team.

The system that they have been working in is not perfect, however.

High Reliability means “what should happen, happens and what should never happen, doesn't.” The Joint Commission has been concerned that there are infrequent events around the country where patients who have received anesthesia have suffered a bad outcome because they were not truly ready to leave the care of the anesthesia team after a procedure, but left anyway. So, to prevent against these rare events, the Joint Commission has a rule that a licensed independent practitioner must evaluate the patient before the patient can go to a lower level of care (the inpatient unit if an inpatient, home if an outpatient). Well, GBMC has not had untoward events that I am aware of, but we have had a significant problem with getting the documentation that the anesthesiologist has evaluated the patient.

Two weeks ago, the PACU joined the units participating in LDM (Lean Daily Management). Charlene Mahoney, the Nurse Manager of the GOR PACU decided with her team to measure daily completion of the Post Anesthesia Evaluation Note as one of their metrics. Earlier this week on LDM rounds, I was stupefied at how fast they had driven their performance to 100% completion of the form! On rounds, Charlene explained that the Team had implemented two process changes to meet their goal. First, she had met with Dr. Lewis Hogge from our Anesthesia group to discuss the charge anesthesiologist rounding on an hourly basis. This helped their compliance but did not get them to 100%. Charlene, CJ Marbley, our Director of Perioperative Services, and Dr. Hogge then decided to put a hard stop in the PACU. No patient would be allowed to leave the PACU without the form being completed. This is a huge culture change for our staff who are trained to keep the unit open for incoming patients from the OR. They have accepted this challenge with the support of Jennifer Trunk, the PACU’s clinical partner and our PACU charge RN's. And, the Team has gotten to perfection in this measure without slowing down the operating room.

Experts in mistake proofing identify three levels of this. The first level is when people remind others of the possibility of an error and ask them to be vigilant. This has a positive effect but since the operators are human, sooner or later someone will get distracted and forget. In healthcare we frequently turn to education of the staff as a level one mistake proofing action.

In level two mistake proofing, we make a process change that improves performance but does not fully stop the error from occurring. In the PACU example, Charlene, Dr. Hogge and their Team did this when they instituted hourly rounding of the anesthesiologists.

Level 3 mistake proofing is when a constraint or “hard stop” is created that totally prevents the bad outcome. An example of this from my daily life is that I cannot start my car without having my foot on the brake to assure that the car doesn't start moving before I intend it to. The PACU Team turned to this successful level 3 action when they stopped anyone from leaving without a signed form.

I am very proud of the PACU Team and grateful for their speedy problem solving to fix this hole in the Swiss cheese and make our patients safer!