Patient Safety: Solving Problems That Were Large in Scope

Patient Safety

By: Joe Paone

Published: 9/11/2019

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Flexible endoscopes were a potential patient safety issue at Baystate Medical Center. Now? Not so much.


Flexible endoscopes are notoriously difficult to clean, putting unsuspecting patients at risk of being exposed to infections by unsuspecting physicians. After a serious flexible endoscope reprocessing error at Baystate Medical Center in Springfield, Mass., the facility’s staff knew it had to immediately improve its entire high-level disinfection (HLD) process. Their efforts earned this year’s OR Excellence Award for Patient Safety.

Diane Betti, RN, MSN, CNOR, CSPDT, ST, and her team took on the task. They audited the situation and found numerous issues. “We didn’t have consistency in process,” says Baystate’s director of inpatient surgery, perianesthesia and sterile processing. “There were inconsistencies in the handling, transport and delivery of flexible scopes.”

The team delved into where in the process there could be potential breakdowns, assigning a code to each one that reflected the potential for it to result in patient harm. For example, a scope that wasn’t cleaned correctly would be assigned a different weight than mistakes in documentation.

Armed with that analysis, the team devised a comprehensive response plan that touched many departments, including sterile processing, clinical engineering, infection control, surgery, endoscopy, anesthesia and process improvement. Here are the key aspects of the new process.

  • Limited access. The first change the Baystate team implemented addressed the relatively easy access to scopes, which led to them being all over the hospital and difficult to track down. “Before, pretty much anyone could go into sterile processing and obtain a scope simply by opening the door of the cabinet, and off it went,” says Ms. Betti. “If a scope was sitting on a counter in SPD, they could grab it.”

SIMPLY RED Dirty scopes are placed in containers with red clips and red biohazard stickers on the outside, and a timer button is attached on the lid.   |  Kathleen Roy/Michael Gudejko, Baystate Medical Center

Now, only an SPD supervisor is permitted to access and assign out a high-level disinfected scope. “This was a big culture change,” says Ms. Betti.

  • Consolidated reprocessing. Baystate was reprocessing scopes across 4 buildings. Now all scope reprocessing is performed in one specialized, renovated area. There was also a “purposeful” decrease in the number of staff members deemed competent in reprocessing of scopes; Ms. Betti says now 4 validated experts dubbed endoscope reprocessing technicians carry out all aspects of cleaning, testing, inspection and disinfecting of flexible scopes. “Tightening up the reprocessing to have it in one area made it easier to maintain consistent practice,” says Ms. Betti. “We can really keep an eye on it and make sure that what we think is a consistent process actually is a consistent process.” With the SPD consolidation, Baystate staff also have better control of the scope inventory; they can monitor if scope reprocessing needs to be prioritized to address a shortage.
  • Scanning and tracking. Baystate hadn’t been tracking or scanning its scopes. Now scopes are entered into a database and scanned with RTLS (real time location system) technology. Staff can search the database anytime and see exactly where a scope is.
  • Timing the process. Ms. Betti says Baystate worked with a vendor to implement timers similar to the white buttons on turkeys that pop up to let you know they’re done. A staffer presses the button when point-of-use cleaning of the scope begins. When the scope is scanned and received by SPD, staff now know how long the scope has been waiting to be disinfected. If the time goes over an hour, causing bioburden to harden, an extended cleaning time is required that includes an extra hour of soaking before cleaning begins.
  • Hard stops. The nurse or tech, with scope and paper form from SPD in hand, says, “I have a [type of scope] that’s been cleaned and high-level disinfected.” The proceduralist says, “I agree” (or something similar). The team confirms the scope’s serial number and verifies with the attached paperwork that it has been cleaned and high-level disinfected. After agreement, the “Clean” white tag attached to the scope is removed. In the EMR, the nurse documents the serial number, model number and validates it was confirmed by the team as “Ready for Use.” A laminated pause reminder is posted in both procedural rooms and ORs.

Culture change

“If there was an error with scopes, it would be automatically blamed on SPD,” explains Ms. Betti. “We really worked on putting a solid, reliable process in place that takes out that ‘blaming’ mentality and becomes more of a collaborative, solution-based approach.”

She says many staffers appreciate the new process: “Everyone knows what to do, which makes things less confusing for them every time they get a scope. To initiate the process, we had a lot of reeducation to do for staff. It was a little bit of a challenge for some of them giving up control. But the process had proven over time to be reliable, which has brought pretty much everybody on board.

“Across our nation, there is still great work to be done in addressing the multitude of gaps known to exist surrounding flexible endoscope utilization and cleaning,” says Ms. Betti.

One thing’s for sure: Baystate Medical Center has done its part to improve its practices in order to protect patients from harm. OSM

HONORABLE MENTIONS
More Innovative Patient Safety... Ideas
SHOW ME A SIGN Procedure room clinicians are informed of patients' special needs with signs placed on their blankets.   |  Centinela Valley Endoscopy Center
  • Safe starts. Patient safety for Centinela Valley Endoscopy Center in Inglewood, Calif., begins at reception: The patient signs in on a label, which a staffer immediately removes for HIPPA purposes. If there’s a similar or soundalike patient last name that day, a color-coded “Name Alert” on the schedule informs staff; the patient’s chart is flagged as well. When transported to pre-op, staff confirm name, date of birth, and that the procedure the patient signed for is correct. After the doctor and nurse complete pre-op tasks, the nurse checks the patient’s ID band and makes sure the proper consent has been signed. Signs placed on the patient’s blanket to advise the procedure room nurse, tech and doctor about special needs — HOH (hard of hearing), dentures, weakness on right side, etc.; that information is also on the patient’s chart.

In the procedure room, the technician and nurse again check the ID band. Once the doctor is ready to begin, a timeout is performed to ensure the nurse, doctor and tech are in agreement that this is the correct patient and the correct procedure. The patient is asked about allergies at various points before the procedure.

  • Fun while learning. Orchard Surgical Center in Salem, N.H., uses annual “skills fairs” as a creative and fun way to keep staff engaged and knowledgeable on the latest in patient safety. Its “Show and Tell” fair found each department taking 3 or 4 topics and procedures and creating short, interactive, hands-on demonstrations. “A Day in the Life of” found each department, including front desk admissions, creating and performing a skit with the help of the nurse manager; the skit followed a patient (played by a staff member) throughout the perioperative day — from front desk to pre-op to the OR and PACU — where a surprise code that was played out. “What If” delved into unexpected situations — an armed intruder, a code in the OR, a power outage, and a surgeon fainting in the OR were just a few. “They were all great, and according to our staff surveys, they loved them and felt the teaching was effective,” says the center’s COO Cathy Dentremont, RN, MBA.
LEAD ACT\OR
LEAD ACTOR Shane Stanford, MSN, (second from left), plays an active role in preparing his staff for any type of emergency.
  • A really realistic drill. MEDARVA Stony Point Surgery Center (SPSC) in Richmond, Va., decided to really spice up one of its patient safety drills earlier this year. Caleb Cox, SPSC’s director of business development and physician network. That live person was Shane Stanford, MSN, SPSC’s director of clinical services. Mr. Stanford, who had splashed water on his face and hair to make it look like he was sweating, casually walked up to a nurse in the surgery center’s PACU and said, “I’m having chest pain and need you to help me. I think I’m having a heart attack.”

The nurse followed protocol and checklists, laid him on a stretcher and began following the typical procedure for a code blue.

After the code call went over the intercom, Mr. Stanford informed the nurse and her team that this was a drill, but they were to continue on as if it were real. The staff followed detailed tasks when responding to the code. The entire test took about 45 minutes. “Training in our surgery centers needs to be as realistic as possible,” says MEDARVA Healthcare CEO Bruce Kupper. “When a real person is the focus of training, it changes the environment. If you can train using simulations as close to reality as possible, it leaves a stronger impression on your staff and is more meaningful.”

— Joe Paone

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