This weekend the Crisis Checklist Collaborative had its 7th meeting in Bangor. With colleagues from Ireland, Holland and Denmark we are working on a set of checklists to improve reliability of response to catastrophic deterioration of patients on normal wards (i.e. outside the operating room or Intensive Care Unit).
Checklists are widely used in high risk industries such as nuclear, chemical or aviation. These happen to be also high reliability organisations whose safe performance is seen as an aspiration for healthcare providers (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3388695/#__ffn_sectitle).
Our learning is that checklists function on several levels: amongst other things they summarise important information, reduce cognitive load and flatten hierarchies by making everybody having access to the same platform. The latter is relevant and allows those with less status but crucial knowledge to speak up.
In broad terms errors fall into two groups: errors of commission and errors of omission. After more reading in Julie Johnson’s Case Studies in Patient Safety (What is normal? And why that matters … ) I have reflected on the opportunities for patients preventing some of the errors. It would seem that errors of omission can be addressed by checklists: The WHO surgical safety checklist is a classical example – it assures that patients have had all their checks done prior to undergoing the procedure. The first part of the list is performed prior to the start of the operation and the patient is likely to be awake and part of the procedure (http://www.who.int/patientsafety/safesurgery/ss_checklist/en/).
So why not take this further?
Deterioration is often proceeded by changes in blood pressure, heart rate or speed of breathing. Could the patient assist with the safety check every time that vital signs are taken. The patient is instructed on admission. The patient reads out the parameters. The nurses calls out the values. The patient compares them to normal values on a simple chart. The chart indicates at which degree of abnormality advice from more experienced medical staff is needed. The nurse and the patient agree the level of escalation. The patient can share the information with relatives and friends. One check by one person replaced by a network of safety assessors using the data to improve reliability. Just a thought.
But probably doable. In our project Safety=Design we developed diaries for patients to document their fluid intake and output. And gave them bracelets to remind them of the importance of communicating urine output and colour (http://www.health.org.uk/programmes/shine-2014/projects/use-traffic-icons-guide-behaviour-health-care-staff-patients-and ). Doable with good results. So patients can actively check the colour of urine and communicate it. A first building block!