A recent report submitted to PA-PSRS concerned a patient whose physician changed a central venous catheter with the patient in the head-up position. The patient suffered an air embolus—a known hazard of open venous access above the heart while in the head-up position. For this reason, such procedures are performed with the patient supine. What seems like an error of commission (changing the catheter with the patient in the head-up position) was more likely an error of omission (missing the essential step of putting the patient in the head-down position).

Reminders are an essential part of monitoring activities in complex environments. The aviation industry, which is frequently cited as a safety-related model for healthcare, recognizes the importance of reminders and incorporates them into crew resource management programs in two ways: through the use of checklists and through encouragement to speak up when observing mistakes.

Table 2 briefly presents the findings of a brief literature search for studies involving clinical experiences using checklists.

  Table 2. Studies of Checklists to Promote Safety in the Healthcare Setting

Objective demonstration of improvement is sparse. A review of patient safety practices commissioned by the Agency for Healthcare Research and Quality (AHRQ) includes several safe practices on the topic of inserting central lines alone, including the use of maximum sterile barriers during insertion, the use of antibiotic-impregnated catheters, and the use of real-time ultrasound guidance to localize the vein.¹² The use of checklists to confirm that each step has been done is a “line of defense” against the imperfection of human memory. Elements of a checklist aimed at preventing the type of event described above might include: verifying patient consent, placing patient in the head-down position, establishing a complete sterile barrier, adequate skin preparation, adequate local anesthesia, localization of vein, correct size/type of catheter, and others.

The AHRQ review did look specifically at pre-anesthesia checklists. Though the available information was limited, the studies reviewed failed to find significant differences in rates of problem identification when these checklists were used. Barriers to effective use include the need for training in the use of the checklists and the heterogeneity of the devices used. Research questions focus on effective methods of implementation, which are related to the sensitivity and specificity of the checklist elements in detecting problems, the effort involved (including redundancy), the yield, and other factors of usability.

Institutions might either want to share their experiences with checklists or think about gaining some experience trying to use checklists to avoid mental lapses, while considering the factors cited above.

A less obvious component of this report is that another healthcare provider had to be helping the physician. Was this assistant aware of the potential complication of air embolus when manipulating a central venous catheter? Did they notice, but were afraid to speak up? Being afraid to speak up is not uncommon. If institutions were to identify this failure as a root cause, interventions might be considered to help change the culture to one of safety in which speaking up about safety concerns would be expected.

Notes

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12. Shojania KG, Duncan BW, McDonald KM, et al., eds. Making health care safer: A critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43. Rockville (MD): Agency for Healthcare Research and Quality; 2001.