CHPSO January 2014 Patient Safety News

January 2014
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In this issue:

Lessons Learned: An alarming finding

Clinical alarm safety has been highlighted by the Joint Commission in recent months as they have identified this as a National Patient Safety Goal (NPSG). CHPSO is analyzing alarm-related reports that have been submitted by our members and is seeing some patterns.

In our analysis, we have to take into consideration how our data is collected. Our data is primarily collected from staff-completed incident reports. Staff are most often compelled to complete a report when an incident occurs that is unusual or severely affects a patient. Therefore, volume of reports by category is not indicative of rate of incidence.

The reports fell into the following categories:

  • Problem with equipment
    • False alarm
    • Broken or defective alarm
    • Improperly attached alarm
  • Staff interaction
    • Staff distracted by alarm
    • Staff disabled alarm
  • Patient/family interaction
    • Patient/family disabled alarm
    • Patient/family wanted alarm turned muted/turned off or removed for reasons of comfort
  • Environmental design
    • Department or room layout contributed to lack of response to alarms (e.g., difficulty hearing the alarm)

In an effort to support our members in meeting the requirements of the Joint Commission NPSG and in providing the best care possible to their patients, we will continue to analyze and evaluate these reports; not only to bring awareness of the problems but to also introduce recommended solutions. CHPSO encourages its members to contribute alarm-related incidents to our database to help build a rich knowledgebase for improvement.

Global Patient Safety Alerts now available on iOS devices

We believe that we can do great things when we join forces and partner to maximize our impact on global patient safety. CHPSO contributes alerts, advisories, and recommendations to Global Patient Safety Alerts.

Global Patient Safety Alerts collects, reviews, and indexes information from its contributing organizations - those who are willing to share what they have learned from patient safety incidents with others for improvement across borders. Launched in 2011, Global Patient Safety Alerts is a project of the Canadian Patient Safety Institute (CPSI) with the support of the World Health Organization (WHO).

You can now access the entire Global Patient Safety Alerts database in the palm of your hand with the new Global Patient Safety Alerts app. We are pleased to note that the sample screenshot Global Patient Safety Alerts uses for its app (see below) shows three alerts, all of which were produced by CHPSO. Download the app for free today to your iPhone, iPad or iPod Touch from the Apple App Store.

Coming Soon: Webinar on new small-bore connectors

CHPSO is taking part in an international effort to create standards for replacing Luer connectors for enteral and neuraxial uses with new connectors to prevent accidental, and sometimes fatal, misconnections with intravenous lines. Meeting California’s Jan. 1, 2016, deadline for implementation of new connectors will be difficult for manufacturers, and CHPSO is working with the FDA, manufacturers and clinicians in other countries to help accelerate standards development and device manufacture in order to meet the deadline.

New challenges will arise during the transition period from universal use of Luer connectors to non-Luer connectors for specific uses. More information about these connectors (including the first pictures of the prototype neuraxial connectors) and the process for establishing the international guidelines is available on the CHPSO website. While much discussion is currently taking place within the patient safety community about the connectors, CHPSO is the only clinically oriented organization actively participating in this phase of the project. Hospitals that have questions or concerns should contact CHPSO directly.

CHPSO plans to schedule a webinar open to all hospitals, discussing the new connectors, the planned industry-wide rollout, and steps hospitals can take to make the change successful. Details about the webinar will be published in CHA News and the CHPSO Patient Safety News as it becomes available.

Potential effects of workarounds

Workarounds are attempts to avoid perceived workflow problems. Workarounds include deviations from procedures, problem solving, improvisation and shortcuts. Workarounds are symptomatic of either workflow or safety culture issues, and often are a combination of both.

A recent article reviewed published reports on workarounds. The following is a brief summary of the positive and negative effects of workarounds expressed in those reports.





Positive effects

Care is delivered according to the patient’s specific needs. For example, ‘batching’ care so that the patient can get a good night sleep; giving medications early so that they won’t be four hours late.

Decrease stress for manager and other staff.

Workarounds may lead to better rules.

Circumvent barriers to delivering care.

Increase efficiency and support work.

Provide excellent information for improvement efforts.

Annotating printed paper patient information sheets rather than only viewing information in EHR, enables clinicians to acquaint themselves more with the patients.



Negative effects

Decrease patient safety by increasing the potential for error.

Make staff vulnerable to retribution.

Prevent organizational learning and improvement through hiding problems and practices that are occurring in real time.

Do not accurately reflect patient care delivery (e.g. charting a medication earlier than it was given)

Time consuming, erode staff time and energy or increase cognitive effort.

Create problems elsewhere in the system and can lead to other workarounds.

Decrease surveillance of patients.

Increase the risk of occupational injuries.

Directly or indirectly cost hospitals money.

Staff work without necessary equipment.

Informal teaching of workarounds is problematic because there is no clarity about what clinicians are being taught.

Contribute to a culture of unsafe practices.

Loss of information about patients.


Potentiate security breaches (e.g. nurses borrowing access codes and posting them for easy viewing).

Create new pathways to error.



Both positive and negative effects





In some instances workarounds enhance patient care but they can also potentiate patient harm.

Workarounds may ease and accelerate performance but increase workload.

Allow the use of CPOE but hide opportunities for redesign and improvement.

Workarounds fix problems so that patient care can continue but in not addressing the underlying problem similar problems may reoccur in relation to patient care.

Help with the coordination of work and reduce cognitive load by providing solutions to recurring problems but lead to unstable, unavailable or unreliable work protocols.

Allow the system to continue functioning but may lead to widespread instability.

While one workaround may prevent medication errors (e.g. using a STOP stamp on the paper medication chart to indicate that a medication has been ceased because the stop and the start orders in the CPOE look very similar) other workarounds using the same system increase error risk (e.g. recording actual administration times on paper medication chart but not in the CPOE).

Fix problems so that patient care can continue but in not addressing the underlying problem similar problems will occur requiring staff to address them again.


Informal handover of information to work around the lack of formal communication channels reduced falls but may create gaps in passed on patient information.

Workarounds may circumvent problematic EPR-mediated communication between staff but may also create confusion if the workaround is not explained.


Deviations are linked with good patient outcomes (innovations) and bad patient outcomes.




Debono DS, Greenfield D, Travaglia JF, et al. Nurses’ workarounds in acute healthcare settings: a scoping review. BMC Health Serv. Res. 2013;13:175.

Reminder: CHPSO / ECRI portal now includes health IT reporting

Recent updates to the CHPSO / ECRI reporting system now include the ability to report health information technology (IT) events under their own category. This upgrade will enable the gathering of additional information about health IT events as well as hazards.

The December 19 CHPSO / ECRI webinar featured a review of this and all updates to the reporting portal and should be available in the webinar archive within the coming weeks. In the meantime you can contact CHPSO for additional information.

No CHPSO member call in January

Due to scheduling conflicts the January 13 CHPSO member call, Alarming Events, has been rescheduled to March 10. If you have already registered, no further action is required as all current registrations have been transferred to the new date. More information about the webinar and registration information can be found at

Event: Getting to the Root Cause - It’s Not About the Form

CHPSO / ECRI webinar

Monday, January 27, 2014, 11:30 a.m. to 12:30 p.m. Pacific Time

Register for this event

One of the most common questions we receive when PSO members embark on a root cause analysis (RCA) is “What is the best form to use for root cause (or event) analysis?”

There are a variety of forms or tools that organizations can use; however, the key to a successful RCA often does not lie in the form itself. It is the thorough investigation and analysis, using appropriate tools such as timelines and cause-and-effect trees that help organizations get to the root cause and implement actions that will have long lasting effects.

This webinar will review the effectiveness of the identification of causal factors and root causes from RCAs that have been submitted by members to the PSO. Based on review of several hundred RCAs, suggestions have been identified to help organizations conduct a better RCA by probing deeper into the “whys” of the event.

This call is for members only. Registration, at no charge, is required and available at A CHPSO website member account is required. Registrants will receive an email January 24 with participation information. Participants registering on or after January 24 should contact CHPSO for participation information at (916) 552-2600.


Event: Practical Application of Process Improvement Tools in the OR

CHPSO monthly member call

Monday, February 10, 2014, 10 to 11 a.m. Pacific Time

Register for this event
CHPSO welcomes Bob Conrad of R-Conrad Consulting, LLC, as he presents an Operating Room case study which will provide participants with the opportunity to learn how to reduce errors by improving operating room processes through the use of the following:

  • practical application of Lean Tools to mitigate risks associated with inefficient and broken processes; and
  • strategies to engage surgeons and staff through change management methodologies that foster a culture focused on patient safety and quality of care.

About the Presenter

Bob Conrad is Owner/CEO of R-Conrad Consulting, LLC, headquartered in Texas. His firm assists organizations in achieving revenue enhancement, cost reductions and improvement of quality through process improvement and change management methodologies.

Continuing Education

Nursing- Provider approved by the California Board of Registered Nursing, Provider #CEP 16084, for 1.0 contact hour. Full attendance, completion of online survey, and attestation of attendance is required to receive CE for this webinar. CE is complimentary for registrants.

This call is for members only. Registration is required and available at A CHPSO website member account is required. Registrants will receive an email February 7 with participation information. Participants registering on or after February 7 should contact CHPSO for participation information at (916) 552-2600.

Upcoming Patient Safety Events

California Hospital Patient Safety Organization

Jan. 27, 2014,
11:30 a.m.‑12:30 p.m.
Getting to the Root Cause: It’s Not About the Form
CHPSO / ECRI webinar
Feb. 10, 2014,
10‑11 a.m.

Practical Application of Process Improvement Tools in the OR
CHPSO monthly member call

Mar. 10, 2013
10‑11 a.m.
Alarming Events
CHPSO monthly member call

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