Mitigate Reoccurring Patient Safety Events that Have the Potential to Delay Care and/or Cause Serious Harm

Purpose: Reduce reoccurring patient safety events that have the potential to delay care and/or cause serious harm.
Background: The most common reoccurring errors in ambulatory care clinics include administering the wrong medication, mislabeling or failing to label a lab specimen, and misidentifying patients. These errors lead to decreased patient satisfaction, decreased quality of care (including delays in care), increased potential harm, and increased cost. These events were named “never events,” meaning that they should never occur by an employee following the correct standard work process.
Methods: We created process that includes K-cards observations and safety pauses to systematically reduce or eliminate reoccurring errors. The K-card is a self- and peer-audit tool that helps to ensure each of the workflow steps are followed correctly. A safety pause is implemented when an employee experiences a “never event.” A safety pause takes place wherever a workflow or task error leads to an actual safety event that involves a patient or a caregiver. The pause allows the team (including the employee that caused the error) to investigate the causes, barriers and action items that can be learned from the event. Electronic tracking of K-cards allows clinic leaders to review results of the observation results. An electronic tracking was created to reflect how many departments are performing K-card audits and to evaluate the results of the process (e.g., how many K-card audits were a pass or fail).
Results: The K-card audit has reduced the number of events related to the workflow. We found that K-card self-audits are a good way of checking our internal processes but found increased benefit in peer audits. Peer audits allow another caregiver to determine if a peer is following all the designated steps involved with the task, thereby increasing the knowledge of two people rather than one. The safety pause provides a time for the employee and the team to reflect on what occurred and why. The entire team shares are part to ensure this type of event does not occur again.
Conclusion: Use of K-card audits and the safety pause process has helped reduce Intermountain’s ambulatory care never events. Common errors in ambulatory care can have serious safety consequences for patients and caregivers (employees/staff). Reducing or eliminating these errors has the potential to improve patient experience by following best practices and leads to safer outcomes.