Wednesday, March 12, 2014

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!


  1. It is alarming to know that the anesthesiologists needed this level of intervention by nursing to get them to comply with the rule. Just like they are exempt from CPOE. What gives? Why doesn't standard work apply to everyone?

    1. Thanks, Anonymous. It takes a team. When we work together we get it done. The Anesthesiologists are doing the work. The nurses are assuring that it is done before releasing the patient.

      We are working now to have Anesthesia use CPO on our units. Meditech does not have the modules required for OR/PACU. We need to get to a better place with our technology before they can eliminate paper ordering.

    2. Dr. Chessare,

      What member of the "team" incurs a disciplinary consequence if a patient is discharged to an inpatient unit or home without a signature from the Anesthesia team? I will assume, as usual, the Nursing staff.

      Your "hard stop" car starting analogy doesn't really apply here- it is very easy to discharge a patient without this signature, I have, and I know others have as well. Understand that many signatures still occur after the fact.

      While skilled nursing staff has always historically assumed reponsiblity for discharge readiness, this new process, while often appropriate with complex patients, is not always practical with stable and predictable patients.

      If there is a missed signature, the responsibility and consequence for that lies with Anesthesia.

    3. Thanks, Anonymous. I am afraid that you are stuck in the old way of thinking that if the end point is not achieved, someone needs to be punished. We do not believe that anyone is "to blame". We think that the system is the culprit and the new design will allow the nurses and physicians to work better together and keep patients even safer. That is why we now use the Just Culture algorithm when we assess people's actions. There are now only negative "consequences" for conscious risky behavior.

      As for the actual changes to make, I will leave that up to the team. They may decide to have a checklist that prompts for the form being signed before the patient leaves the PACU. Thanks very much for sharing your ideas on how to make the system better with Charlene, Dr. Hogge, and the other members of the Team.


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