Making a safety list and checking it twice

This is a post by Dr. Rod Tarrago, a pediatric intensive care physician at Children’s Hospitals and Clinics of Minnesota.  He is also the Chief Medical Information Officer and is proud to admit he’s a computer geek.  He’s been helping improve the care at Children’s through the use of technology and spends most of his time helping other clinicians improve their understanding of the computer system. He’s the proud father of two young boys and future computer geeks. 

For nearly three years, the Pediatric Intensive Care Unit (PICU) at Children’s has been using a time-tested technique to improve care of patients: a safety checklist. It’s well known that it’s very difficult — if not impossible – for the human brain to truly multitask.

Unfortunately, in an ICU environment, where patients are sick and their illnesses complex, clinicians have to integrate a lot of information and make many decisions on a daily basis. There are also many “typical” tasks that need to be accomplished for every patient, every day.

In order to help the team remember to address all of these items, we’ve been using a safety checklist as part of our work since 2010.  In St. Paul, we go through this checklist during patient rounds.  In Minneapolis, since the unit is larger and busier, we do special “Safety Rounds” later in the workday.

On both campuses, the entire care team, including physicians, nurses, pharmacists, respiratory therapists, and nutritionists, comes together every day to go through the “standard list” of 23 safety items. These include reminders to check the need for IV and bladder catheters, make sure that antibiotics are needed, and order new labs each day. Each clinician specialty “owns” individual items and then brings them to the group for daily discussion, making sure that everyone is on the same page. Initially, we started this project by using a laminated paper checklist that was placed at each bedside. After losing too many checklists, we moved to an electronic checklist that is embedded in each child’s electronic medical record or EMR.

We recently examined 21 months’ worth of data after using the checklists and found some exciting results:

  • By asking whether we really needed catheters, we reduced the use of these catheters by anywhere from 25 to 45 percent. We also found that we used those catheters less.
  • By asking ourselves whether any medications can be given either orally or through a feeding tube instead of through an IV, we cut costs to families. We examined one medication, a diuretic, and found that by using the checklist, we used an IV 46 percent of the time instead of 77 percent of the time.  By using IV catheters less often, we reduce the risk of catheter infections. It’s also less expensive to give a medication orally compared to through the IV.  We saved patients’ families more than $64,000 over the study period by making these changes.
  • By simply discussing the need for antibiotics each day making sure that we identified ahead of time how long the antibiotics should last, we lowered our use of antibiotics.  In fact, by entering this information into the patient’s EMR, we found that we gave one less dose per patient each day.
  • Prior to the checklist, we ordered labs several days in advance. Now, the checklist reminds us to order them each day and discuss the need for each lab.  By doing this,  we reduced the number of labs we ordered by almost six labs per patient per day. This saves a family $500 a day in lab charges.

You may use a checklist at home or to run errands. In medicine, it’s a relatively new concept that’s only beginning to grow in popularity. But in our PICU, it’s the standard.

 

 

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