CHPSO newsletter.

May 2014

In this issue:

Lessons Learned: Creating a More Effective Surgical Time Out

The following case study is derived from incidents reported to CHPSO

The Case

A patient was scheduled for surgery on the left ring finger. On the day of surgery, the site was verified with the consent. A verbal verification was given by the patient to the anesthesia provider and the circulating RN that the procedure to be completed was on the left ring finger. The surgical site marking, which was performed in the surgeon’s office two days prior to the procedure, was verified. The staff verified the consent, the booking form and the OR board which all indicated the procedure would be on the ring finger. When the surgeon entered the room, the RN led the team time out which verified the patient’s ID, allergies, and read aloud the consent form reflecting the ring finger. All members of the team verbalized “yes” to the patient and procedure. When beginning the procedure, the surgeon recalled that he still had in his mind that the surgery was on the middle finger and consequently performed the procedure on the middle finger.

Wrong-site surgeries were identified by The Joint Commission (TJC) as a national patient safety concern in 2003 and required compliance with a Universal Protocol to improve safety, which was revised in 2010 (follow this link to obtain a printable copy of the TJC Universal Protocol poster).1 However, there has been little evidence to support that the time out process has improved the incidence of wrong-site surgeries. The time out checklist itself appears thorough. The solution to a more effective time out is not in improving the checklist but in changing how we are conducting the time out.

Surgeon led time-outs

The surgeon is viewed as the leader of the surgical team and evidence has shown that hospitals that have experienced improvement in wrong surgeries practice surgeon initiated time outs.2 An insider’s view of the time out is explained by a surgical resident who was asked by the attending surgeon to lead a time out:

“Having the opportunity to run a time-out gave me a new perspective on the process. Previously, I saw it as a redundant pause in the action to again ensure we were operating on the correct side. Presumably, prior to the time out, the surgical team has confirmed with the patient the correct procedure and laterality and then marked the correct side. Additionally, the pre-op nursing staff, the OR staff and the anesthesia team have all confirmed this prior to the patient ever being placed under anesthesia. So it’s easy to understand how the surgical time out can be seen as just a formality that need not be taken too seriously. But after having the opportunity to run a time out and think critically about each of the items, it became clear that the surgical time out is much more than just re-confirming the laterality. It’s a final opportunity to make sure that everyone is on the same page and prepared for the case and that all necessary items are available….As a resident, the surgical time out has even more to offer- the opportunity to think about case preparation in a systematic manner so that when I’m an attending I can ensure that not only are my cases safe but they are efficient and allow me to provide excellent outcomes by ensuring that I have everything at my disposal.”3

It can be easy to see how the assumption could be made by the surgeon and other members of the team that so many measures had been taken to ensure that the correct patient and site were identified that the final time out seems redundant. But, as the case study above demonstrates, the wrong surgery may be performed if the surgeon has not actively engaged in the time out process.

The point of the time out is to create a pause where everyone stops what they are doing for just a moment to verify that everything is correct. However, the time out process is only effective if it is used effectively, with consistency, and in the spirit in which it is intended.


  1. Universal Protocol. The Joint Commission. Available at Obtained April 20, 2014.
  2. Feldman, DL. The Inside of a Time Out. May 2008. Agency for Healthcare Research and Quality. Available at Obtained April 20, 2014.
  3. Stitzlwin, R. Let’s Take a Time Out For Patient Safety. December 2013. Residency Secrets. Available at Obtained April 20, 2014.

Collaborating for Safety

My first safe table forum experience

Safe Table Forums are a collaborative platform for hospitals to discuss patient safety issues in person. In these protected and confidential meetings, clinicians and staff share their safety event experiences in a frank and open manner. Safe Table Forums are conducted by California Hospital Patient Safety Organization (CHPSO) and the Regional Hospital Associations for those hospitals that are member of both organizations.

Claire Manneh is filling CHPSO’s newly created Project Manager position. Below is her first-hand account of her experience at one of CHPSO’s regularly-scheduled safe table forums.

Setting the [Safe] Table Straight

Unsure of what to expect of attending my first safe table, I entered the meeting room with a blank slate, introducing myself to the various quality and safety personnel from local hospitals. Dr. Rory Jaffe facilitated the discussion and introduced a vital topic—alarm management—that was requested by stakeholders attending previous meetings. Representing most hospitals in the region, these participants—many with clinical backgrounds, others with clinical engineering responsibility and all leading their hospital’s work in this area—were all engaged in the conversation, and transparent about sharing their hospital’s safety issues and successes.

The Safe Table

While these hospitals are competitors, the neutrality and confidentiality provided by the Patient Safety Work Product (PSWP) rules allows for openness in this setting. The intent is to make the environment comfortable enough to freely share challenges a hospital faces and potential areas of improvement. To this end, PSWP provisions ensure that the discussion remains confidential and legally privileged. Participants may take information learned back to the institutions but cannot identify the source provider or hospital. Even the initially quiet first-timers attending warmed up to the group. Understanding that their experiences are shared among other hospitals, there was a sense of relief. A variety of perspectives were represented at the meeting where attendees  shared their own insights into similar experiences and the approaches they had taken at their facilities to mitigate risk of harm to patients.

Opportunity Knocking

Attendees typically discuss complex challenges resonating in all health care facilities today. As we develop greater understanding of the socio-technical factors behind patient safety, we are finding that the issues underlying any event or problem, as unique as the problem may appear, occur at most hospitals. Through the exchange of ideas at safe table forums, solutions are both shared and created, leading to shared improvement plans. These forums are safety nets and productivity boosters. If you are interested in participating in a Safe Table Forum, please contact Rhonda Filipp.


Patients Are Not Aircraft


The successes of other industries help point the way to achieving reliable, safe health care. However, analogies may go too far. The difficulty of finding meaningful, reliable and economically produced measures of quality and safety highlights one of many distinctions between air travel, a common model of high reliability, and healthcare.

Aviation, like most other high reliability industries, has technologic objects central to critical human actions and the sources of much of the data. For example, engineers can and have extensively instrumented aircraft—often sending real-time aircraft health and pilot performance data, supplemented by “black boxes” to maintain a record in case of catastrophic failure. A massive stream of data is produced in the normal course of work without need for manual data entry.

In health care, our work centers on a human being and many critical actions are between provider and patient, without a simple way to automate data collection. Bar code medication administration represents one set of critical actions for which we have developed data collection, but even there, it requires human intervention to record.

Until we automate recording of and data capture from provider-patient interactions, which is well beyond current technologic capabilities, we will have significant information gaps and difficulty automating all data collection. Monitoring quality and safety in health care is inherently more difficult than in technology-centered industries.

Yet we should take advantage of technology when we can, and many opportunities exist to improve our data collection and monitoring, both real-time and retrospective. The challenges of clinical alarm management highlight one of the areas where aviation has significant lessons.

Boeing and Airbus have increased integration of alerts and displays (EICAS and ECAM, respectively), and display recommended actions, frequently in checklist form. The alerts are prioritized and relatively intelligent, based on data gathered from the many systems in the airplane.

Contrast that with how we manage alarms in complicated patients. Each device has its own set of alarms and its own priorities that may not be consistent with the patient’s priorities. For example, an infusion alarm priority for maintenance fluids should be markedly different from one for a vasopressor unless the maintenance fluid is carrying the vasopressor, and should indicate significantly different actions. Also, information from multiple sources (e.g., pulse oximetry, end-tidal CO2, and ventilator) should be evaluated in concert, improving alert specificity.

While there is much “low-hanging fruit” in alarm management, such as eliminating monitoring for patients who don’t require it, maintaining high quality sensor placement and careful selection of alarm thresholds, major advances in alarm management will require integration for better evaluation and prioritization.

The Joint Commission National Patient Safety Goal on Alarm Management, Phases I and II, can be met without high levels of system integration. However, we should not be satisfied with the current state, and should work with our many vendors to improve device-device communication, perhaps including device communication standards. Only then can we truly manage alarms intelligently.

Small Bore Connector Update

May 2014

CHPSO continues to work with the device manufacturers and international standards organizations to help hospitals meet the January 2016 deadline for implementation of incompatible connectors for epidural, enteral, and intravenous uses.

The enteral device suppliers should be able to start introducing new devices to market 4Q 2014. This will start with administration sets, followed in three months by syringes, and, three months later, tubes. During the transition period, the administration sets will have “transition connectors” allowing connection to legacy tubes. The transition period is prolonged for several reasons; the primary being that feeding tubes tend to remain in patients for an extended time.

Epidural and other neuraxial connectors are due to be released on a tighter timeline. The new standard fitting is being revised, as testing has shown the ability to cross-connect with Luer fittings in certain circumstances. The revisions will probably add several months to the timetable, as device testing for usability and performance needs to be repeated with the newly revised fittings.

CHPSO and the neuraxial device manufacturers will be meeting frequently (currently twice a month) to work towards timely release of the new devices in the California market, as well as the USA and the rest of the world. Our next webinar on the topic is June 18 and is open to all organizations, CHPSO member or not. See for more details.

EHRs: Unintended Consequences

Without a doubt, Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) are here to stay. (And in a nutshell, an EMR is a digital chart of a paper record, whereas an EHR is not only a digital chart, but also it’s a comprehensive history of a patient’s health record that can be shared with other providers.) The immediate and potential benefits of these electronic systems are numerous: convenience, improved patient care, preventive care and research. As these electronic systems are becoming more commonplace in healthcare organizations, it is becoming clear that there are unintended safety risks associated with communicating the patient’s healthcare through EHRs.

In their 2013 EHR simulation pilot study, Christopher March et al. tested the efficacy and safety of an EHR within an ICU environment at an academic medical center.1 The primary purpose of this study was to determine how often providers would recognize medical errors in the EHR within a high fidelity simulated environment. The results were troubling. Of the 38 participants, consisting of interns, residents and fellows, the average error recognition rate was 41 percent. The least recognized error was over-sedation (16 percent), but 68 percent of participants recognized poor glycemic control. A small population (32 percent) recognized inappropriate antibiotic testing. While this pilot study does not report whether a simulated environment improves provider use of the EHR, it demonstrates the practicality of an EHR simulation to identify patient safety issues within the EHR and interface.

The Institute of Medicine’s 2011 report on HIT details the unintended consequences of EHRs including data fragmentation, over-completeness (redundancy and copy-and-paste), errors in data recognition, and cognitive recognition.2 The risks stemming from the use of health IT can be improved upon, but requires vendors and healthcare organizations working together to determine how to improve these systems. That is now happening, and the ONC (Office of the National Coordinator for Health Information Technology) is leading many of these efforts.

Training clinical staff on how to reduce the risks involved with using an EHR can further improve the delivery of quality care. EHR simulation is gaining popularity as an instrument to measure user competency and improve patient safety. Competency in an EHR requires time, and there are many improvement opportunities in both system design and end-user training.


1. March CA et al. Use of simulation to assess electronic health record safety in the intensive care unit. a pilot study. BMJ Open 2013; 2:e002549 doi: 10.1136/bmjopen-2013-002549
2. Warden GL, Bagian JP. Health IT and patient safety: building safer systems for better care. Washington, DC: Institute of Medicine, National Academies Press, 2011.

UPDATED: Syringes and Infusion Lines – Big Changes Ahead

CHPSO webinar – open to all; membership not required

June 18, 2014, 10 to 11 a.m. (Pacific)

Register for this event using credit card

Register for this event using check

This session is updated from the March 26 presentation, and includes the newest plans for assessing neuraxial connector needs and revised introduction plans and labeling for the devices. Participants of the March webinar may register for this session at a reduced price of $49; see Tuition tab below for further instructions.

Historically, the Luer connector was used for many incompatible purposes: intravenous infusions, epidural catheters, enteral feedings, blood pressure cuffs, etc. Misconnections have occurred with catastrophic results.

California law will soon mandate that hospitals use mutually incompatible connectors for three purposes: intravenous, neuraxial (e.g., epidural), and enteral. While the law driving the adoption deadline is in California, hospitals throughout the world will be making this change. CHPSO is now meeting periodically with device manufacturers to help hospitals meet the January 2016 deadline.

Hear the inside story, from one of the few on the International Standards Working Group involved in planning the deployment of the new devices.

Major changes will occur in the supply chain and at hospitals. Prepare your hospital for the change, and understand some of the potential pitfalls ahead.

Registration is required and available at the top of this section.  Registrants will receive an email June 16 with participation information. Participants registering on or after June 16 should contact CHPSO for participation information at (916) 552-2600.


  1. Why California mandated the change.
  2. The problem with proprietary solutions.
  3. Standardization and testing of the new connectors.
  4. Supply chain challenges, and hospitals’ role in addressing these.
  5. The need for specific assessment of neuraxial device use in hospitals.
  6. Plan for introduction of new connectors.
  7. New risks arising during the changeover and after.
  8. Hospital material management challenges.


Dr. Rory Jaffe is the Executive Director of the California Hospital Patient Safety Organization (CHPSO), the oldest and one of the largest PSOs in the United States. He represents the only PSO voice on the International Standards Working Group to resolve the problems with small bore connectors. He has extensive experience in both clinical care and health system leadership. Prior to establishing CHPSO, he was Executive Director of Medical Services for the University of California system. In this role, he served as the senior physician in the system, which included oversight of quality of care at the five academic health systems and the ten student health centers. He also has served on a number of federal and state advisory committees.

Recommended Audience

Nurses, Pharmacists, Materials Managers, Physicians, and Quality and Patient Safety Leaders.

Continuing Education

Nursing- Provider approved by the California Board of Registered Nursing, Provider #CEP 16084, for 1.0 contact hour. Tuition payment, full attendance, completion of online survey, and attestation of attendance is required to receive CE for this webinar. All attendees requesting CE must be registered.


$99 per registrant.

$49 for attendees from March 26 webinar (contact Asma Ahmad for one-time use discount code)

Cancellation Policy

A $25 non-refundable processing fee will be retained for each cancellation received in writing by June 18. No refunds will be made after this date. Substitutions are encouraged. Cancellation and substitution notification may be emailed to

HQI Annual Conference

Accelerate Excellence

November 6, 2014 - November 7, 2014

Registration opens May 9 at

Join HQI November 6 & 7 in Huntington Beach, CA, as we discover, learn, engage and commit to advance and accelerate patient safety and quality improvement. National experts will join California experts to share knowledge, experience, and resources to advance transformation through the themes of Vision to Action, Evidence to Practice, Outcome to Income, and Patient to Partner.


  • Eric J. Topol, MD: American cardiologist, geneticist, and researcher, named #1 Most Influential Physician Executive in Healthcare, 2012 by Modern Healthcare.
  • Barbara M. Balik, EdD, MS, RN: Principal, Common Fire Healthcare Consulting, Senior Faculty at the Institute for Healthcare Improvement, and member of the National Patient Safety Foundation Board of Governors.
  • Warren Browner, MD, MPH: CEO of California Pacific Medical Center, Senior Scientist in the CPMC Research Institute and Professor (adjunct) of Epidemiology & Biostatistics at UCSF.
  • Jeffrey B. Cooper, PhD: Director, Center for Medical Simulation; Professor of Anesthesia, Harvard Medical School
  • Clifford Y. Ko, MD, MS, MSHS, FACS: Director of the National Surgical Quality Improvement Program, and Division of Research and Optimal Patient Care American College of Surgeons
  • Ian Morrison, PhD: Futurist, author, and President Emeritus, Institute for the Future.
  • David Perrott, MD, DDS: Senior Vice President & Chief Medical Officer of California Hospital Association.
  • James L. Reinertsen, MD: Head of The Reinersten Group, winner of the 2011 John L. Eisenberg Individual Achievement Award.
  • Thomas Salerno, BA, MPA: President and Chief Executive Officer at St. Mary Medical Center, a Dignity Health Member.
  • Ronan Tynan, MD: Irish tenor, recording artist, physician, and champion disabled athlete.
  • Paul Uhlig, MD, MPA, FACS: Cardiothoracic surgeon internationally recognized for practice and study of high reliability health care teamwork and patient/family centered care.
  • More to be announced!


Regency Hyatt Huntington Beach Resort and Spa
21500 Pacific Coast Highway
Huntington Beach, CA 92648

Discounted room rate of $219 (plus tax) is available (while supplies last) through Wednesday October 15, 2014 online or by calling (888) 421-1442 and mentioning "HQI Conference".


The California Hospital Patient Safety Organization is one of the largest Patient Safety Organizations in the nation, serving hospitals in the Western United States. CHPSO confidentially collects and analyzes patient safety data, develops and shares best practices, and helps individual hospitals accelerate safety improvement. More than 300 institutions have joined in this quest to eliminate preventable patient harm. CHPSO collaborates with hospital associations to ensure an integrated approach. It also maintains close alliances with other statewide PSOs, quality and safety agencies, research institutes and think tanks. As a result, members gain unprecedented access to the collective intelligence of patient safety experts and innovators. For more information, visit

Upcoming Patient Safety Events

May 19
11:30 a.m.–12:30 p.m.
Developing Corrective Action Plans: The Do’s and the Don’ts
CHPSO / ECRI webinar
June 18
10–11 a.m.
UPDATED: Syringes and infusion lines – big changes ahead
Open to all; membership not required

Hospital Council of Northern and Central California

May 7
8:30 a.m.–2:45p.m.
Patient Safety First Education Programs and Luncheon

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