Tuesday, October 21, 2014

Getting to Level 3 Mistake Proofing

Lean Daily Management (LDM) has been a very valuable tool in moving us closer to our vision, creating many more focused problem solvers than we’ve ever had. Phil Komenda, our Director of Imaging and Cardiac Services, and his team have been working to move our electrocardiogram (EKG) reading closer to 100% reliability. Their standard for success is that every EKG will be officially read by a cardiologist within 24 hours of the completion of the study.

Phil’s team of nurses, technicians, cardiologists and other managers has significantly improved the percentage of EKGs read within 24 hours.

Some of the changes that Phil’s team has adopted include:

a.      Placing written instructions and reminders on each EKG cart.
b.      Having the nursing units transmit EKGs instead of waiting for the cardiology tech.
c.      Assigning cardiology techs on each unit to help with staff training.
d.      Sorting the EKGs to be read from the oldest to most current.
e.      Increasing the stream of communication to inform cardiologists when there is an EKG to be read.

When they began their improvement efforts, roughly 9 out of 10 EKGs were read within 24 hours. Now, roughly 97 out of 100 are read on time. This is great improvement, increased reliability by almost a factor of 10!

So now the challenge is how to get rid of the 3 errors per 100. One of the most common reasons why the study is read more than 24 hours after it was completed is because it was not transmitted to the cardiologists in time. Phil’s team has tried educating staff members of the importance of transmitting the study as soon as it is done, citing getting it read quickly so as not to miss a possible heart attack or arrhythmia as critical. This is called level 1 mistake proofing. Education is a powerful tool if the staff members are not aware of the importance of the official read.

The written instructions and the reminder on the cart itself to transmit the EKG as soon as it completed is an example of level 2 mistake proofing.  This is a more powerful strategy than simply reeducating staff members because it the text is actually present on the cart in front of the person doing the study when he or she has completed it. As you can see from Phil’s team’s results, this has helped. However, you can imagine a nurse or nursing tech who has just done an EKG and showed the strip to a Hospitalist then getting interrupted and forgetting to push the TRANSMIT button. The reminder on the cart is helpful but imperfect.

This week I had a discussion with Phil about meeting with the suppliers of EKG machines to see if any of them have a device that automatically sends the study when it is done, thereby taking operator forgetfulness out of the mix. This is an example of level 3 mistake proofing and it is what all good engineers, especially those working in high-risk industries, strive for. If it was your child who was being checked for a potentially life-threatening but uncommon arrhythmia, 3 errors in 100 is just not good enough. Let’s see what Phil learns…..stay tuned.

I want to thank those that posted comments on my recent blog that focused on the first Ebola Virus Disease (EVD) case in the U.S.

While it is still very unlikely that we will see a case of Ebola at GBMC, we must prepare for that possibility. Our ED has responded a few times over the last few weeks when patients presented with positive responses to the screening questions but were later found to not be at risk for Ebola.  I am very grateful for our staff’s hard work and for the fact that they were prepared, using the appropriate personal protective equipment until they found that the patient was not at risk.

We have a team, led by our Chief Operating Officer, Keith Poisson, that is following this situation very closely and is assuring GBMC’s readiness according to the directives from the Centers for Disease Control. Our work in Ebola preparedness can be found on the Infoweb. There you will find a schedule for training our people in the use of personal protective equipment. We are starting with those most likely to need to use the equipment.

GBMC must be ready to serve our community if a patient with Ebola ever presents. We must communicate well and remain calm. We must avoid contributing to misinformation and doing things that are not indicated by the evidence, for these responses only make people more fearful. My thanks to the entire GBMC team for their professionalism and their commitment to evidence-based care.


  1. Thank you for your measured commentary regarding Ebola. It seems as though most of the hysteria surrounding this virus has subsided. I am thankful for Kaci Hickox and the Maine Judge who have stood up to the fear, misconceptions and opportunistic politicians.

    The statics on influenza deaths are much more alarming. While we at GMBC are currently screening all incoming patients for foriegn travel, we are not screening them for flu vaccine, nor are we offering them. What can we do to make flu shots available for our patients in all areas of the hospital?

  2. Thanks, Anonymous.

    We began screening all inpatients for influenza vaccine status and offering the vaccine to those who have not had it on October 1st. Our primary care practices are screening all of their patients for this as well.


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