CHPSO newsletter.

November 2013
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In this issue:

Lessons Learned: "Other" conditions in database

If you have run an Event Type summary report in our ECRI database, you have noticed that the largest category by volume is “Other” for the CHPSO aggregate. As we have been reviewing events classified as “other” we have noticed some common themes: non-team promoting behavior (physician), poor coordination of care, and delay in care related to insufficient staffing. Over the next few months, we will look closer at each of these issues.

Disruptive and non-team promoting behavior

Here are a couple of examples of the types of reports we are receiving about behavior that is disruptive for the health care team, as well as for the patient.
  • A physician attempted unsuccessfully 9 times to place a nasogastric tube. He refused assistance from nursing staff. The patient experienced a vagal response and a code blue was activated.
  • During rounds a pharmacist asked if the patient should be on GI prophylaxis because he had a nasogastric tube in place and had recent abdominal surgery. The physician’s response was to draw up his fingers like a gun and “shoot” the pharmacist for asking the question.

Suggested strategies to address this problem

In 2008, the Joint Commission identified disruptive behavior as a problem and issued the Sentinel Event Alert “Behaviors that undermine a culture of safety”. The following year, they added a new Leadership standard for all accreditation programs that addressed disruptive and inappropriate behaviors in two of its elements of performance (EP):
  • EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors
  • EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.
In addition, six core competencies are to be addressed in the credentialing process under the Medical Staff chapter, including interpersonal skills and professionalism.

Additional suggested actions

  • Educate all team members –both physician and non-physician- on appropriate professional behavior defined by the organization’s code of conduct. The code and education should emphasize respect and include training on basic business etiquette (particularly phone skills) and people skills.
  • Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff –regardless of seniority or clinical discipline– in a positive fashion through reinforcement as well as punishment.
  • Make use of mediators and conflict coaches when professional dispute resolution skills are needed
Determine what steps your organization has taken to implement these Joint Commission recommendations and whether or not they are reinforced when addressing disruptive and inappropriate behavior.


Gessler R, Rosenstein A, Ferron L. How to Handle Disruptive Physician Behaviors. Am Nurse Today. 2012;7(11):8-12.
Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. July 9, 2008. Available at

New connectors are coming

Luer connectors were invented in the late 1890s to provide leak-free connections between glass hypodermic syringes and needles, while allowing easy fitting and removal by pushing together and pulling apart (“Luer slip”). Several years later, a variant was made with threads so that the connectors would be screwed together and secured ("Luer-lock").  Luer fittings became the standard for intravenous use, and then became popular for many other uses requiring small-bore connectors, from attaching blood pressure cuffs to inflation sources to connecting epidural catheters to anesthetic infusions. With so many different applications using the same connector, accidental cross-connections, some fatal, began to appear.

A 24-year-old woman was 35 weeks pregnant when she was hospitalized for vomiting and dehydration. A bag of ready-to-hang enteral feeding was brought to the ward, and the nurse, assuming it was total parenteral nutrition that the woman had received on previous admissions, pulled regular intravenous tubing from the floor stock, spiked the bag, and started the infusion of tube feeding through the patient’s peripherally inserted central catheter (PICC) line.  Both mother and fetus died.

The risk of deadly cross connections like this can be significantly reduced by adopting physically incompatible connectors for different uses. For example, if the enteral feeding system were attached to an administration set with a connector incompatible with a Luer intravenous fitting, then the care giver would be unable to accidentally connect the enteral feeding administration set to the intravenous line.

Until now, there has been no standard for non-Luer fittings to accomplish this objective. Hospitals wishing to institute mechanical barriers to cross connections have been faced with the challenges that proprietary connectors pose—such as introducing new cross-connection risks and device incompatibilities between institutions.

Soon there will be international standards for specialized connectors specific to neuraxial (e.g., epidural and intrathecal), blood pressure cuff, urinary, enteral and breathing/ventilator systems; each mechanically protected from connecting with the other. These connectors will also be protected from connecting with Luer fittings, which will continue to be used for intravascular and hypodermic applications.

This international standards initiative is led by the International Organization for Standardization [ISO] committee. CHPSO is a member of the USA section of the ISO standards committee and is involved in planning the transition from the current set of connectors. Manufacturers are striving to meet California's January 2016 deadline mandating physical barriers to cross connections between enteral, neuraxial and intravascular applications.

Phased introduction plan for each class of connectors. Each phase in this plan lasts six months.
New challenges will arise during the transition period from universal use of Luer connectors to non-Luer connectors for specific uses. For example, when the UK instituted non-Luer connectors for neuraxial uses, a hospital in Wales received a shipment of the new, non-Luer spinal needles before it was expected. This only came to light when an obstetric patient had the spinal needle inserted, the clinician went to connect the syringe of medication, and found that the two would not connect. The needle was removed, a Luer spinal needle found, and the procedure repeated.

Plans are being made that satisfy the following goals:
  • Assure clinician usability comparable to current Luer devices
  • Generate awareness of the reason for and the introduction of global standards
  • Facilitate rapid adoption of new global standard small-bore connectors
  • Integrate the new connectors with minimal disruption to the supply chain and clinical practice
  • Develop and execute timeline delivering focused messaging, programs and measures for success
  • Manage specific messaging for respiratory, enteral, and limb cuff, neuraxial, and intravascular/hypodermic suppliers (as well as possible future applications) launching the new international small-bore connectors
To avoid some of the compatibility challenges experienced by the UK, for each new connector that is released, all manufacturers will simultaneously change from Luer to non-Luer connectors in order to “flush out” the legacy devices from the supply chain. During the transition period, each non-Luer device will include a Luer adapter to ensure that Luer-to-non-Luer compatibility issues are obviated. Practitioners should be aware that, during the transition period, the presence of these adapters will allow cross connections, and the provided adapters should only be used after double checking the two items being connected.

The new connectors will be launched in sequence, starting with the enteral connectors, then probably neuraxial, with the others to follow. The current plan is to wait six months between each launch; however, the timeline may be contracted to assure meeting the January 2016 deadline. CHPSO is working with manufacturers to help meet this deadline.

Sample  for neuraxial use. Neuraxial male connectors will have a tip diameter about 20%  smaller than Luer male connectors. Two variations of these connectors: “lock” type with threads (pictured), typically for longer term use such as epidural infusions, and “slip” type, frequently used in procedures such as lumbar puncture.  For neuraxial, all male connectors will have a collar as pictured, which helps prevent cross-connection with the larger caliber female Luer intravenous connector.

Read FAQs about small-bore connectors and tubing misconnections

Is training ever useful?

A frequent response to an adverse event is to retrain the staff. However, training is often criticized as a very weak and inappropriate response to problems, unlikely to result in significant sustained improvement. That criticism is correct, to a point.

A recent paper discusses the difference between appropriate and inappropriate training from the human factors standpoint . Training as the sole or primary intervention may be of marginal value as system design issues are often part of the problem.

Additionally, training is likely to be inappropriate if the organization is encountering significant system design issues and the organization is trying to:
  • get people to stop using something incorrectly.
  • fix an error being committed by a number of people.
  • change innate human characteristics (e.g., increase vigilance).
  • get people to remember safety training they previously had.
Training is likely to be more appropriate:
  • when introducing new devices or systems.
  • when using simulation to practice procedures or responses to specific problems.
  • for sensorimotor skill training, e.g., mentored procedures, simulation.
  • when system issues are comprehensively addressed as part of the response to the adverse event.


Russ AL, Fairbanks RJ, Karsh B, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ quality & safety. 2013;22(10):802–8.

“I’ve got your back:” Mutual support reduces errors and improves culture

Part 3 of the Working as a Health Care Team series

NFL coaches agree that on a football team, the two most important players are the quarterback and the left tackle. The quarterback is obvious – they are the leaders of the offensive. But the left tackle’s job is equally, if not more, important. The left tackle’s job is to protect the quarterback from what he can’t see coming – to protect his blind side.(1)

The health care delivery team, consisting of physicians, nurses, pharmacists, and others is analogous to a sports team – working together to achieve a common goal. This analogy holds true especially when referring to the team dynamic: in order to be a successful team, individual members must utilize their strengths and skills to provide additional support to their team members.

Working as a team by supporting and taking initiative to help colleagues is especially important in health care, as doing so can evade some of the most substantial problems that occur in health care delivery.  Members of a health care team generally work long hours under stressful circumstances. It is understandable how fatigue may negatively affect an individual’s reaction time, as well as critical thinking and problem solving skills. During these times, it can be reassuring that your coworkers “have your back.”(2)

Picture obtained from AHRQ’s TeamSTEPPS program.

In order for mutual support to be effective, it must be seen as a cultural norm. Otherwise, individuals may conclude that people do not trust the quality of their work and are watching over their shoulder to see if they make a mistake.  Colleagues need to feel that it is safe to speak up or intervene to prevent a coworker from making an error or use poor judgment. And colleagues receiving this information need to accept it knowing that it is an expectation that the team keeps an eye out for one another. Both the ability to take constructive criticism as well as the courage to offer feedback to colleagues are signs of respect and dedication to the success of the entire healthcare team.


1. The Blind Side. Burbank, CA: Warner Home Video, 2010.
2. Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS: Situation Monitoring. Available at:

Safe pain medication prescribing in emergency departments

In an effort to reduce death and addiction due to prescription drug abuse, a set of guidelines and other resources for emergency departments to use have been released. These guidelines are a collection of recommendations developed by the San Diego County Medical Society (SDCMS) Prescription Drug Abuse Medical Task Force, a group that includes representatives from Imperial County as well. They draw on published medical literature and the experience of various groups across the country. These are guidelines, not policies. Physician discretion is acknowledged in applying them.

All practitioners who prescribe pain medications are encouraged to review the Safe Pain Medication Prescribing Guidelines. Topics include:
  • Cures Reports
  • Pain Assessment
  • Acute Pain Treatment Recommendations
  • Emergency Department Pain Treatment
  • Chronic Pain Treatment Recommendations
  • Chronic Pain Dosing Recommendations
  • Weaning Opiates
  • Side Effect Management
  • Concomitant Prescriptions
  • Red Flags for Prescription Drug Abuse and Fraud
  • DEA Reporting
  • Addiction Referrals
  • Educational Materials
Patient educational flyers are available in Spanish or English that explain why emergency departments follow certain guidelines in an effort to promote safe management of the patient’s pain.

San Diego Safe Prescribing has made these materials available on their website.  CHPSO encourages emergency departments to review these materials and consider similar actions in their own facilities.

Ask CHPSO: What is a PSES, really, and how much detail does it require?

Providers have great flexibility in designing a Patient Safety Evaluation System (PSES); the following answer describes a “bare bones” PSES focused on reporting events to CHPSO.

A typical PSES is the event evaluation and review plan in place at your facility. From the moment an event is discovered, what is the process that your team takes to document and review what happened? Who is involved? Which groups have access to this information? How is the information maintained and secured?

Perhaps start by making a work flow chart of the process, from the moment an event is discovered up through submitting the event to your PSO, and then create a detailed description of that work flow chart. Additional details you will need to define include:
  • What is protected as Patient Safety Work Product (PSWP)?
    • Event reports that you plan to submit to CHPSO are protected, as is the event review and evaluation of those events.
    • You may, prior to submitting an event to CHPSO, change your mind and unprotect the event report.
  • What information will you submit to your PSO?
    • Usually, this will be reports of events, near misses and unsafe conditions.
    • You are not required to submit all information to your PSO. HOWEVER,
      • Not submitting a particular event report means that report will not be protected.
      • Submitting only a subset of events (e.g., medication events) means that the PSES and PSWP privilege only apply to that subset. Other events are not protected.
      • The more events submitted the better; not submitting events means events cannot be compiled to discover trends, create lessons learned or even recognize possible manufacture errors.
  • How is information submitted to your PSO?
    • Electronically through your event tracking system
    • Manually online
A PSES does not have to be complicated. The PSES should meet the distinct needs, objectives, and structure of your organization. A PSES is not a one-size-fits-all proposition. The construct of a PSES for a small rural physician office may substantially differ from a PSES designed to support a large academic medical center. The PSES is fluid in that you may alter the system at any time to meet changing needs or organizational structure—just be sure that your policies, procedures, and staff education are kept up-to-date to reflect any changes to the defined PSES.

Just take a deep breath and do your best to document your facility’s process that is already in place. This may already be documented, so you just need to review it for accuracy, add the PSO/PSWP information, and give it the title of “Patient Safety Evaluation System”.

Additional tools and assistance, a policy template, and past webinars can be found by members at (website user account required). CHPSO Staff is happy to briefly review your PSES when it is completed.

"Ask CHPSO” is a regular column in the monthly Patient Safety News and is intended to provide answers to common inquiries.  If you have a question, please contact us at (916) 552-2600 or All inquirers will remain anonymous.

Event: Engaging Staff & Leadership in Patient Safety

Free webinar for members and non-members

Monday, November 11, 2013, 10 to 11 a.m. PT

Register for this event

Geri Schimmel, RN, MS, LHRM, Director of the Baptist Health Safety Partnership, will share Baptist Health South Florida’s success in developing a Patient Safety Champion program. The innovative involvement of frontline staff is the foundation of their program. These champions volunteer for this frontline role, sharing information, best practices and knowledge with coworkers at meetings; keeping patient safety opportunities in the forefront; encouraging colleagues to be aware of and speak up for patient safety; conducting unit-specific patient safety rounds; using storytelling; recognizing and rewarding employees for doing the right thing.

In addition to frontline staff involvement, more than 250 managers and senior executives have participated in leadership Patient Safety Champion training to support their frontline Champions. Every new leader receives patient safety training and new employee orientation includes a session with mini-champion training for new nurses. Baptist Health’s President/CEO includes patient safety training at executive and Board retreats. 


  • Identify three (3) key reasons to implement a patient safety champion program.
  • Establish criteria for selection of champions and training content.
  • Define three (3) concepts to implement and sustain your champion program/patient safety culture.

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 free for all participants. Registration is required. Registrants will receive an email November 8 with participation information. Participants registering on or after November 8 should contact CHPSO for participation information at (916) 552-2600.

Event: Be a T.R.A.C.E.R. not a Racer! Preventing Tubing Misconnections

CHPSO / ECRI webinar

Monday, November 18, 2013, 11:30 a.m. to 12:30 p.m. PT

Register for this event

Patients have multiple tubing lines connected to them for reasons such as monitoring, delivery of medications and nutrition therapy, and oxygen delivery. When misconnections occur, it can cause serious and sometimes fatal outcomes. Tubing misconnections, however, are almost always the result of human error (e.g., related to time pressure or miscommunication)  and almost always preventable.

The call will discuss how to identify potential tubing connection errors, misconnections, and prevention strategies, including the ECRI Institute T.R.A.C.E.R.™ technique.

This call is for members only. Registration is required and available at A CHPSO website member account is required. Registrants will receive an email November 15 with participation information. Participants registering on or after November 15 should contact CHPSO for participation information at (916) 552-2600.

Event: NAPSO Health IT Safety webinar

Tuesday, November 19, 2013, 10 to 11:30 a.m. PT

Members Only: Register for this event (CHPSO website member account is required)

NOTE: This session was rescheduled from October 10 due to the Federal shutdown. Those who registered for the October 10 session will need to re-register for the November 19 session. We apologize for the inconvenience.

Best practices for capturing the benefits of health information technology (IT), while also reducing risk of patient harm, is on everyone’s mind, including the Office of the National Coordinator for Health IT (ONC).

Join us for this presentation by ONC Senior Policy Analyst, Kathy Kenyon, and Dr. Karen Zimmer from ECRI Institute about what they have learned from their “deep dive” into health IT-related events and the important role PSOs will play in promoting health IT safety.

ONC — Coordinating with Providers, PSOs, and EHR Developers on Health IT Safety

ONC’s Health IT Safety Plan relies on the private sector, especially health care providers, PSOs, and electronic health record (EHR) developers, to integrate health IT into effective patient safety programs. This presentation will acknowledge some of these efforts and ONC’s plans to support them over the next couple of years. We have something approaching consensus that health IT has the potential to reduce hazards found in paper-based delivery systems, while recognizing that health IT can create new hazards if not well designed, implemented, maintained, monitored, and used properly. This presentation will describe ONC-sponsored work that is designed to assist health IT safety efforts in the private sector, including newly designed tools.

A PSO Deep DiveTM into Health IT Related Events

As health care organizations adopt health IT systems, such as electronic health records, risk managers and patient safety must identify strategies to address the “unintended consequences” of the technology that can cause patient harm. While health IT has the potential to provide multiple benefits to health care, it can also contribute to errors if, for example, data is entered incorrectly or the system malfunctions. This session will briefly discuss where we are with EHR adoption and review health IT errors and events that have been reported to one PSO with a national presence.

Event: HTSI webinar series on alarm systems management

Registration now closed

AAMI Foundation Healthcare Technology Safety Institute (HTSI) offered a free webinar series on alarm systems management, starting in September and ending April 29, 2014. We are pleased that HTSI has reached attendee capacity but regret to inform our readers that registration is now closed.  For those unable to register in time, HTSI will provide the opportunity to view the recordings and download the materials at after each webinar is presented.

The recorded webinar and other resources are now online for the September 25 webinar, “How Do We Get Started?” The remaining webinar series includes:

October 30, 2013: How to Identify the Most Important Alarm Signals to Manage

December 3, 2013: How to Manage Alarms at the Bedside

January 28, 2014: Best Practices for Alarm Management – Palomar Medical Center and Johns Hopkins Hospital

February 25, 2014: Best Practices for Alarm Management – Abbott Northwestern Hospital and Intermountain Healthcare

March 25, 2014: Best Practices for Alarm Management – Kaiser Permanente and Children’s National Medical Center

April 29, 2014: Educating and Training Your Staff: Circling Back to Your Policies and Procedures

Patient Safety Alert: Patient fall risk associated with bed-exit alarm reset time

Our partner, ECRI Institute, has issued a patient safety alert concerning bed-exit alarms. Some bed-exit alarms do not immediately reset after sounding. During the reset process, which may take several seconds, there may be no indication that the alarm is not activated. If a patient exits the bed during this reset interval, the alarm will not sound, increasing the likelihood of patient injury.

Bed-exit alarms are devices designed to alert staff when a patient is attempting to exit the bed. The type of alarm used in the reported incident was a pressure sensor that fits under the patient, either as an integral part of the bed or as a removable sensor pad. Once the alarm has been activated, the process for resetting it will vary from brand to brand. With some models, patients will need to lie back on the bed and remain there for a short period of time (10-30 seconds) to enable the reset. With other models, staff will need to manually reactivate the alarm before it will sound again, but even then there may be a short period of time before the alarm is ready. Because bed-exit alarms may not be fully operational immediately after being activated or reset, users of these alarms are encouraged to adhere to the recommendations below. Although the focus of this report is on pressure sensing models, other bed exit alarms designs may also have alarm reset requirements.
ECRI Institute recommends the following:

  • Determine the alarm reset procedure for each bed-exit alarm model in use in your facility. The procedure for resetting alarms will vary based on the alarm manufacturer, model, and individual settings. This information can be found in the alarms’ instructions for use and bed manuals that have integrated bed alarms.
  • After assisting a patient in returning to bed, staff should remain with the patient for an appropriate period of time (based on alarm type and settings) to ensure the alarm is properly reset.
  • Bed-exit alarms are not a substitute for good judgment and practice. Staff should be aware that alarms will not prevent patients from attempting to leave their beds, and some patients may exit their beds faster than staff can respond to the alarm. Staff are encouraged to closely supervise patients who may be prone to noncompliance (because of dementia, restlessness, incontinence, etc.) and take steps to reduce their desire to leave their bed (such as providing assistance to the toilet at regular intervals).

To review the full alert, please log into your ECRI account and go to the Patient Safety E-lerts Archive.

Upcoming Patient Safety Events

California Hospital Patient Safety Organization

Unless noted, all CHPSO events are for members only, are free and require registration. The registration link will be located on each webinar’s webpage. All times are for the Pacific Time Zone. For more information, contact or call (916) 552-2600.
November 11
10–11 a.m.
Engaging Staff & Leadership in Patient Safety
Free to members and non-members
November 18
11:30 a.m.–12:30 p.m.
Be a T.R.A.C.E.R. not a Racer! Preventing Tubing Misconnections
CHPSO / ECRI Webinar
December 3
10–11 a.m.
How to Manage Alarms at the Bedside
AAMI Foundation’s HTSI Webinar Series on Alarm Systems Management

Hospital Council of Northern and Central California

November 14 BEACON Patient Safety Exchange In-Person Meeting
South SF Conference Center, South San Francisco

Hospital Association of Southern California

November 5 Southern California Patient Safety First Collaborative
Montebello, CA

Hospital Association of San Diego and Imperial Counties

For more information visit or contact Alicia Muñoz.

November 19
7:30 a.m.–3 p.m.
Achieving Person-Centered Care in San Diego and Imperial Counties
Scottish Rite Center

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