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Valuing Incidents of Excellence

The Marriage of Investigations Data with other Quality Improvement Efforts

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When discussing patient safety topics in the past, I have been careful to relate specific topics to the broader focus on improving quality outcomes.

After all, measuring quality performance is like calculus, with many variables changing at the same time. Thus, reviewing patient safety data in isolation gives a distorted view of overall quality.

To begin with, there must be a foundation of accreditation and external validation inspections that determine whether an institution has incorporated appropriate structures and processes to enable it to provide the highest quality healthcare. Next comes measurement of an array of quality performance metrics that should be monitored. The portfolio of quality measures is a mosaic that includes patient safety data, clinical quality process and outcomes measures, performance improvement project data, financial performance metrics that focus on highest quality at lower costs through efficiency efforts, and malpractice claims data. Finally, and by no means an afterthought, important measures of quality include patient perceptions that specifically address what matters most to them.

Today I would like to focus on investigating incidents of excellence. Learning from these examples can be just as useful as learning from instances where things have gone wrong. An incident of excellence provides an opportunity to learn from and incorporate systems and processes that work safely and well, rather than only incorporating changes that arise as a result of patient safety adverse event incident investigations.

Case Study:

A four-year-old child presented to an emergency department in the middle of the night with a history of severe shortness of breath and noisy, hoarse breathing. He had been seen 36 hours previously for minor upper respiratory symptoms, common this time of year. Upon arrival in the ED he had been triaged by a young nurse and placed in a cubicle at the end of a hallway, far from the nurses’ station to await clinician evaluation. He was febrile, toxic appearing and was notably drooling and leaning forward while in his mother’s lap.

Fortunately, a more experienced pediatric nurse observed the patient being carried to the remote cubicle, alerted the emergency room physician of her concerns, and the physician immediately examined the child. A presumptive diagnosis of impending airway obstruction, most likely due to acute epiglottitis (a hugely inflamed covering flap of the trachea), was made. Anesthesia and surgical staff were urgently paged and the child was intubated under controlled conditions. Next, the child was to be transported to the intensive care unit accompanied by five clinical staff, along with various monitors, oxygen canisters, portable resuscitation equipment and medications.

As this was the middle of the night, the housekeeping staff had just finished waxing the floors outside the elevators that provided direct access to the ICU. A custodian became concerned that the slick, freshly waxed and buffed surface of the floor might be a hazard for the hospital gurney and the accompanying medical staff, and he alerted the emergency room doctor of his concerns. He then raced upstairs to a storage room and retrieved two long rubber mats, which he placed adjacent to the elevator doors extending into the ICU. Once they were in place, he alerted the ER team that transport now could take place safely. The child was transported to the ICU, where he remained for three days before extubation and transfer to a general pediatric ward.

On the day of transfer to the general pediatric ward, the custodian was casually walking along the corridor in the evening when he was approached by one of the house officers who was aware of this gentleman’s role in assuring the child’s safe care on the night of admission. The house officer took the custodian into the patient’s room to introduce him to the child’s parents, saying, “Mr. Jones is a member of the healthcare team that cared for your child on the night of admission. He brought to our attention a serious potential hazard that might have interfered with your child’s safe transfer to the ICU and implemented a plan to overcome the hazard.” The child’s mother rose from her seat and embraced Mr. Jones, sobbing onto his shoulder. Joy and meaning.

This case study identified two instances of excellence, both of which then were incorporated into clinical practice: First, processes to enhance triage of children with respiratory illnesses to ensure correct placement near the nurses’ station and rapid assessment by ER staff. Second, checklist confirmed consultation with custodial team members to address any known or evolving hazards that might interfere with safe transfer of acutely ill patients from the ER to appropriate inpatient settings.

Although we have much to learn from lessons of investigations when things have gone wrong, equally we have much to learn when things go right. Incidents of excellence enable us to value a broader range of opportunities for learning and improvements.

Daniel Cohen

Leading Patient Safety & Quality Consultant

20 March 2017