Improving Resuscitation Timing: Random Assignment of Interprofessional Team Leaders in Simulated Resuscitation.

OBJECTIVES: The aims of the study were to assess whether preassigning a team leader influences resuscitation timing using simulation and to examine relationship between response timeliness and designated leader's profession, whether physician or nurse. METHODS: This is a prospective study of intervention (leader assigned) and control (no assigned leader) teams of residents and nurses participating in a simulated scenario. The primary outcome was time to bag-valve-mask (BVM) ventilation. A secondary outcome measure compared difference in time to BVM between physician- and nurse-led teams. RESULTS: We assessed 25 teams, leader assigned (n = 14) or control (n = 11), composed of 92 clinicians. Leaders emerged in most of the controls (10 of 11). The median time to BVM in the leader-assigned group was 41.5 seconds (interquartile range, 34-49 seconds) compared with 53 seconds (interquartile range, 27-85 seconds) for controls (P = 0.13). In the leader-assigned group, 85% (12 of 14) of teams initiated BVM in less than 1 minute compared with only 54% teams (6 of 11) in controls (P = 0.18). Among the leader-assigned teams, we randomly assigned residents to lead 8 teams and nurses to lead 6 teams. All the nurse-led teams (6 of 6) initiated BVM in less than 1 minute compared with fewer physician-led teams (6 of 8) and only approximately half of controls (6 of 11, P = 0.19). CONCLUSIONS: The leader-assigned teams and controls did not differ in resuscitation timeliness. Among leader-assigned teams, the differences in time to BVM between physician- and nurse-led teams were not statistically significant. However, all 6 nurse-led teams demonstrated timely resuscitation, suggesting a direction for future research on the feasibility of bedside nurses taking the lead during resuscitation, pending code team arrival.

Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory.

OBJECTIVE: To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices. DATA SOURCES/STUDY SETTING: We reviewed and drew examples from studies of organization theory and health services research. STUDY DESIGN: After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA). PRINCIPAL FINDINGS: HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors. CONCLUSIONS: Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures.

Correlation of the predictive ability of early warning metrics and mortality for cardiac arrest patients receiving in-hospital Advanced Cardiovascular Life Support.

BACKGROUND: The Modified Early Warning Score (MEWS) helps identify patients experiencing a decline in physiological parameters that indicate risk for cardiac arrest (CA). OBJECTIVES: To assess the association between MEWS values and patient survival following in-hospital CA. METHODS: Retrospective cohort study of patients who experienced in-hospital CA. The relationship between CA survival and MEWS values as well as other risk factors such as age, gender and type of electrographic cardiac rhythms was analyzed using logistic regression. RESULTS: Survival rate to hospital discharge was 21%. Strong predictors for survival were MEWS values at hospital admission (p < .002), younger age (p < .005), ventricular fibrillation (p < .0001), and ventricular tachycardia (p < .0001). Gender and MEWS 4 hours prior to CA were not significantly associated with survival. CONCLUSIONS: Survival following CA was significantly associated with MEWS at hospital admission but not 4 hours prior to CA. The type of cardiac rhythm and age were also predictive of survival.

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

BACKGROUND: Inadequate supervision is a significant contributing factor to medical errors involving trainees, but supervision in high-risk settings such as the intensive care unit (ICU) is not well studied. OBJECTIVE: We explored how residents in the ICU experienced supervision related to medication safety, not only from supervising physicians but also from other professionals. DESIGN, SETTING, MEASUREMENTS: Using qualitative methods, we examined in-depth interviews with 17 residents working in ICUs of three tertiary-care hospitals. We analyzed residents' perspectives on receiving and initiating supervision from physicians within the traditional medical hierarchy, and from other professionals, including nurses, staff pharmacists, and clinical pharmacists ("interprofessional supervision"). RESULTS: While initiating their own supervision within the traditional hierarchy, residents believed in seeking assistance from fellows and attendings, and articulated rules of thumb for doing so; however, they also experienced difficulties. Some residents were concerned that their questions would reflect poorly on them; others were embarrassed by their mistaken decisions. Conversely, residents described receiving interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Residents relied on nurses and pharmacists for nonjudgmental answers to their queries, especially after-hours. To enhance both types of supervision, residents emphasized the importance of improving interpersonal communication skills. CONCLUSIONS: Residents depended on interprofessional supervision when making decisions regarding medications in the ICU. Improving interprofessional supervision, which thus far has been underrecognized and underemphasized in graduate medical education, can potentially improve medication safety in high-risk settings.