How to Ensure Safety at Work

According to industry leaders at RSNA 2013 this week, there are three main components to making sure your workplace is as safe as it can be: having a daily management system, maximizing staff safety, and implementing risk management strategies.

"For many people, creating a safe work environment requires a cultural transformation, and that deals with people's habits and how they get their work done. But you can't necessarily focus on that directly," said Lane Donnelly, MD, vice president, chief medical officer and physician-in-chief at Nemours Children's Hospital. "In a way, it's like learning to swim. If you focus on the molecular structure of the water, you'll drown. You need to focus on your strokes. It's the same way with the culture of safety."

Daily management systems

As a start-up hospital that brought together providers and staff from various other facilities, Nemours was able to design and implement a daily management system from the ground up. The result has been a streamlined process that enables providers and staff at all levels to contribute to workplace safety.

"There are four key elements to daily management systems," Donnelly said. "You have to define the leadership's standard work, visualize having control over the processes you're working on, have a daily accountability process in place - and, then, you have to have the discipline to do the first three things."

To meet these goals, Nemours implemented the huddle system. This tiered system requires each clinical area to have a morning huddle with its front-line staff. Those huddles then send a representative to the patient-flow huddle, also known as the bed management huddle. A third huddle meeting – the integration huddle – includes representatives both clinical and non-clinical services, as well as all other services throughout the hospital.

These huddles are held in front of dry erase boards, and they give providers and staff the opportunity to raise any issues and discuss potential problems. Each meeting has three parts: a review of metrics and goals, that day's readiness assessment, and defined problem accountability.

As part of the metrics and goals discussion, employees talk about patient and family experiences, care delivery, and the associated cost and engagement required to provide care. Goals can be updated daily, weekly, or monthly, Donnelly said, but Nemours has chosen to address one goal per day.

Readiness assessment includes methods, equipment, supplies, and associates (MESA). For example, staff can discuss any issues that affect their daily workflow, including broken equipment or a lack of orange juice for children coming in for scans.

Each problem is assigned to a staff member, and he or she is required to report back when the problem has been addressed. Posting this information on the dry erase board keeps each one accountable, and it clears up any misunderstandings about who is responsible for an issue.

The daily management system also addresses the need for interchangeable leadership. When one lead physician is out of the office, another provider can step in and fulfill the daily responsibilities.

Since introducing the daily management system in October 2012, Nemours has streamlined its ability to address problems in a timely fashion. In the past six months, the facility has identified 252 complex issues, most of which occurred in the first weeks after opening. Today, the median time to resolution is five days, Donnelly said.

Staff safety

The two biggest areas that affect staff safety are the ergonomics of work stations and the environmental and procedural risks they face daily, said Olga Brook, MD, a vascular and interventional radiologist at Beth Israel Deaconess Medical Center and assistant professor of radiology at Harvard University.

According to recent research, she said, 58 percent of radiologists and technologists who signs of repetitive stress, and 38 percent are diagnosed with repetitive stress syndrome. Much of these symptoms are due to unavoidable activities - working with a PACS, lifting heavy patients, or daily lead apron use.

These symptoms can be alleviated with simple steps, she said, such as using adjustable-height chairs and tables, keeping computer monitors at eye level, using back support, and avoiding any twisting. Sonographers should also keep their backs and necks in a neutral position by keeping the equipment in front of them. This decreases stress on the body and lowers the likelihood of injury.

Radiologists and technologists also face a risk from droplet exposure with the greatest danger coming from tuberculosis. When working with patients with either a known of suspected case of tuberculosis, Brook said, staff should wear fitted masks with N95 microfilters. In addition, a HEPA filter should be used to clarify the air both 30 minutes before and after the patient is in the room.

Needle sticks and exposure to bodily fluids also pose a risk, but there are easy steps to mitigate the likelihood of an accident, Brook said. Based on current research, among needle stick incidents, there is a 6 percent to 30 percent risk of contracting Hepatitis B, a 1 percent to 10 percent risk of acquiring Hepatitis C (though 85 percent of these employees become chronic carriers of the condition), and a 0.3 percent risk of contracting HIV.

Retractable needles and scalpels, sponge-containing needle holders, and vacutainer devices are among the tools available that help prevent needle sticks. However, Brook said, her hospital instituted a "no recapping" policy. Once the needle is out of the cap, it never goes back in. This protocol minimizes needle manipulation, she said. It's also important she said to wear all the proper protective gear -- caps, gowns, gloves, and shielded masks – when doing interventional procedures. Masks are important even if you wear glasses because fluids can still splatter on unprotected areas.

Risk management

It's been no secret over the past decade that medical malpractice suits can be a heavy burden on providers and facilities. In fact, data from a 2007-2011 study from CRICO, the company that insures roughly 30 percent of all physicians, revealed that during that time, 18,000 claims were filed against providers or their facilities. The payout against all specialties was $3.6 billion, and radiology was the 7^th most frequently accused specialty.

Based on CRICO data, radiology was help responsible in 782 cases, lost $211 million, and 46 percent of those cases resulted in death or permanent injury. And, 68 percent of incidents occurred in the outpatient setting.

This data makes it clear, said Ronald Eisenberg, MD, JD, a thoracic and musculoskeletal radiologist and associate director of the radiology residency program at Harvard University, that all employees must join the band wagon in trying to reduce risk in any way possible.

"Any clinical or administrative activities that a healthcare organization can identify to reduce risk of injury or loss to patients, personnel, or visitors should be considered to cover anything adverse that could possibly happen in a healthcare situation," he said. "Rather than wait for legal action, a request of records, patient complaint, or a billing disruption, employees should immediately notify risk management departments when they encounter untoward or unusual incidents."

The most critical aspect of risk management, he said, is communication. As the provider, it is incumbent upon you to report urgent findings to the referring physician immediately. All other findings must be transmitted within three days. In emergency cases, you must speak to the physician whenever possible, and when you can't, you must leave the information with another licensed healthcare professional. You should also have a process in place to ensure there was appropriate follow-up to any unusual findings.

Communication with patients is also important, he said, especially when getting their permission to go ahead with a procedure.

"Explain everything in language that a patient can understand. Don't use technical terms," he said. "If the patient can't understand, then they can't give informed consent. Conveying information at an 8^th-grade level is generally considered successful in gathering consent."

For those times with negative incidents still occur, Eisenberg said having a paper trail of your actions can be paramount. For example, when an incident occurs, record your actions and your memory of the event immediately on an incident report form. Having a written record at the time of the event can be invaluable in malpractice cases – any other documentation created after the fact will be inadmissible in court.

Eisenberg also suggested that radiologists check into how their states treat malpractice cases and physician apologies. Some states might require a "cooling-off period" before patients can file a lawsuit, he said. This time can give the hospital and the provider an opportunity to proactively answer the patient's questions and, potentially, avoid a malpractice case.

Even in instances where it seems the facility or provider will side-step a lawsuit, communication - and recording communication - is extremely valuable, Eisenberg said.

"Document, document, document. If you don't put it into dictation or into the patient's chart that you said something, then you did not say it," he said. "It's not enough that you remember saying it to them. You have to document when you said, to whom you said it, and what exactly you said."